Common Gynaecological Problems

Postmenopausal bleeding is any vaginal bleeding 1 year after the last period. Often postmenopausal and other abnormal bleeding will have no sinister cause. However it can be the first sign of cancer so it is important to be investigated.

Causes of Postmenopausal Bleeding

Polyps: These are growths, usually noncancerous, that can develop in the uterus, on the cervix, or inside the cervical canal. They might cause bleeding.

Endometrial atrophy (thinning of the endometrium): The endometrium, the tissue that lines the uterus, can become very thin after menopause because of lower estrogen levels. This may cause unexpected bleeding.

Endometrial hyperplasia: In this condition, the lining of the uterus becomes thick, and bleeding may occur as a result. Obesity may be the cause of the problem. Some people with endometrial hyperplasia may have abnormal cells that can lead to endometrial cancer (cancer of the uterine lining).

Endometrial cancer (uterine cancer): Bleeding after menopause can be a sign of endometrial cancer.

Other causes: Hormone therapy, infection of the uterus or cervix, use of certain medications such as blood thinners, and other types of cancer can cause postmenopausal bleeding.

During your visit the doctor will conduct a physical examination and scan. Ideally this scan will be vaginal however this is not always appropriate. We will then discuss with you if you require further investigations. Management may sometimes be in the form of a minor surgical procedure – hysteroscopy, dilatation and curettage to evaluate the lining of the womb

The PAP smear test helps to pick up minor changes on the cervix, allowing cervical pre-cancer to be diagnosed. Not all abnormal smear tests are pre-cancerous. Some can be due to atrophy (dryness) or infection. Approximately 1 in 20 cervical smear test results are abnormal.

According to the PAP smear result, the doctor may recommend further investigations such as a colposcopy. This can be conducted within our clinic on the same day. If changes are detected, a biopsy can be performed before deciding on further treatment such as a Loop Electrosurgical Excision Procedure (LEEP) or laser cone biopsy. These minor procedures are performed in Day Surgery Centre of your choice.

Menstrual problems are common amongst all women. A variety of reasons can cause these problems, including hormonal disturbances.

Some discomfort around menstruation may be tolerable by most women. However, evaluation is recommended if you have excessive pain needing medication or persistent pain when you are not menstruating.

A common condition associated with dysmenorrhea is endometriosis.

Endometriosis is a condition where the lining of the womb migrates to other areas such as the ovaries/ the external surface of the womb. This can lead to inflammation and pain. Women may have problems getting pregnant if the condition affect the ovaries and fallopian tubes.

On average during your period you will up to 80 mls of blood. If you lose more than this you may have menorrhagia.

Signs which may indicate you have heavy periods can be:

• The need to change your sanitary towel every two hours or more than 5 per day
• Passing large blood clots
• Bleeding through to your clothes or bedding. (also known as flooding)

If left untreated, excessive loss of blood each month can lead to anemia (low blood count) which can make you feel tired and weak. This can affect your quality of life and lead to stresses on your body organs including the heart and brain.

There are many conditions that can cause heavy menstrual bleeding, including fibroids which affect 20-30% of women. Fibroids are non-cancerous or benign growths located in the uterus.

Even if no organic cause is found for the heavy menses, treatment in the form of medication is usually effective.

The specific emotional and physical symptoms attributable to PMS varies, but the pattern of symptoms is predictable, occuring consistently during the ten days prior to the start of the menstrual period, and vanishes either shortly before or shortly after the start of menstrual flow.
The most common symptoms noted are: Low mood, Irritability, Breast Tenderness, Bloating.

The normal hormonal changes which occur during the menstrual cycle are thought to be the cause. A course of hormone controlling medication or a change in contraception method depending on the the patient’s needs can be considered for treatment.

Enlargement of the female pelvic organs is usually detected during pelvic internal examination or an imaging such as CT scans or pelvic ultrasounds.

Pelvic masses may originate from gynecologic organs (cervix, Uterus, Uterine adnexa) or from other pelvic organs (intestine, bladder, ureters, skeletal muscle, bone).

Common reasons for a pelvic mass include fibroids and ovarian cysts. However, it can be something more serious in the form of malignancy. It can also affect your reproductive ability.

Type of mass tends to vary by age group.

In infants, in utero maternal hormones may stimulate development of adnexal cysts during the first few months of life. This effect is rare.

At puberty, menstrual fluid may accumulate and form a vaginal mass (hematocolpos) because outflow is obstructed. The cause usually an imperforate hymen; other causes include congenital malformations of the uterus, cervix, or vagina.

In women of reproductive age, the most common cause of symmetric uterine enlargement is pregnancy, which may be unsuspected. Another common cause is fibroids, which may extend outwards. Common adnexal masses included graafian follicles (usually 5 to 8 cm) that develop normally but do not release an egg (called functional ovarian cysts). These cysts often resolve spontaneously within a few months. Adnexal masses may also result from ectopic pregnancy, ovarian or fallopian tube cancers, benign tumors (eg, benign cystic teratomas), or hydrosalpinges. Endometriosis can cause single or multiple masses anywhere in the pelvis, usually on the ovaries.

In postmenopausal women, masses are more likely to be cancerous. Many benign ovarian masses (eg, endometriomas, myomas) depend on ovarian hormone secretion and thus become less common after menopause.

The evaluation of the mass can include a physical examination and investigative tests such as a transvaginal ultrasound and blood tests. Your doctor will discuss all diagnosis and treatment options with you in detail to create a specific plan suited to your individual case.

Endometriosis is a condition where endometrium, tissue from the lining of the uterus, forms and grows in places outside the uterus. These growths may lead to pain and infertility. Up to 50% of women who have endometriosis may experience infertility.

Besides infertility, some women with endometriosis deal with painful periods and painful sexual intercourse, among other symptoms. Other women experience no symptoms and discover the endometriosis only after an infertility evaluation.

Endometriosis symptoms vary from woman to woman. Some women will have many symptoms, while others will have no symptoms besides infertility. With that being said, the following are potential risk factors and symptoms of endometriosis. If you’re experiencing any of these symptoms, you should speak to your doctor.

• Painful Menstrual Cramps
• General Pelvic Pain
• Painful Sexual Intercourse
• Heavy Menstrual Periods
• Infertility
• Depression and Fatigue
• Bladder Problems
• Constipation/Diarrhea
• Family History of Endometriosis

The only way to confirm a diagnosis of endometriosis is with diagnostic laparoscopic surgery. This is an outpatient procedure that involves making a small incision in the abdomen, through which the surgeon inserts a tube with a special camera and, if needed, small surgical instruments.

To diagnose endometriosis, the surgeon will look for visual evidence of endometrial growths. If found, a biopsy of the tissue may also be performed to confirm things. The doctor should also use the surgery to evaluate the severity of the endometriosis (known as staging). In mild to moderate cases, your gynaecologist may even treat the endometriosis during the diagnosis surgery.

While laparoscopic surgery is the only way to confirm endometriosis, your doctor may order other tests including ultrasound, MRI, or CT scan to investigate cysts or other reasons for pelvic pain or infertility.

Treatment of endometriosis will depend on the severity of the disease, if you’re experiencing pain, your age, and on whether you want to get pregnant. Some treatments for endometriosis would lead to decreased fertility, which would not be an option if you’re trying to conceive.

Laparoscopic surgery to remove endometrial growths, scar tissue, and adhesions caused by the endometriosis. This is not a cure, and endometriosis may return later. However, some women will have increased fertility for up to 9 months after surgery.
In mild to moderate cases, IUI treatment along with fertility drugs may be used.
The pain of endometriosis may be treated with over-the-counter pain medications, acupuncture and lifestyle changes, such as regular exercise and diet changes. Surgery to remove endometrial growths is also an option in treating the pain of endometriosis.
If you do not want to get pregnant, treatment options may also include hormonal treatments (which stop ovulation and prevent pregnancy) or, in cases of severe endometriosis, hysterectomy. Hysterectomy, which involves removing the uterus alone or sometimes along with the ovaries, is considered a treatment of last resort. You can’t get pregnant after hysterectomy. Speak to your gynaecologist before exploring this option.

A follicle houses the maturing egg during the menstrual cycle and releases the egg when you ovulate. Occasionally, a follicle doesn’t open to release the egg or recloses after releasing the egg and swells with fluid, forming an ovarian cyst. This is usually harmless and goes away on its own. But large cysts may cause pelvic pain, weight gain, and frequent urination. Ovarian cysts can be identified with a pelvic exam or ultrasound.

Schedule an appointment with your gynaecologist if your cyst becomes very painful or red. This could be the sign of a rupture or infection. A gynaecologist should check your cyst even if it is not causing any pain or other problems. Abnormal growths can be a sign of cancer. Therefore, your gynaecologist might want to remove a tissue sample for testing.

Using anti-inflammatory medications: Cortisone injections can reduce inflammation in a cyst.

Surgical removal of the cyst: This may be used when draining does not work. Hard-to-reach internal cysts can be surgically removed instead of drained if treatment is needed.

Fibroids grow in the wall of the uterus and are sometimes called fibroid tumors, but they are not cancerous. Fibroids are common in women in their 30s and 40s and usually cause no problems. However, some women may experience pressure in the belly, low back pain, heavy periods, painful sex, or trouble getting pregnant. Talk with your doctor about treatments to shrink or remove problematic fibroids.

Most women have no symptoms. That is why most patients with fibroids do not know they have them. When symptoms do develop, they may include:

• Anemia (as a result of heavy periods)
• Backache
• Constipation
• Discomfort in the lower abdomen (especially if fibroids are large)
• Frequent urination
• Heavy painful periods
• Pain in the legs
• Painful sex
• Swelling in the lower abdomen (especially if fibroids are large)

Other symptoms may include:

• Labor problems
• Pregnancy problems
• Fertility problems
• Repeated miscarriages

In most cases, the symptoms of fibroids are rarely felt and the patient does not know she has them. They are usually discovered during a vaginal examination.

Ultrasound: If the doctor thinks fibroids may be present he/she may use an ultrasound scan to find out. Ultrasound can also eliminate other possible conditions which may have similar symptoms. Ultrasound scans are often used when the patient has heavy periods and blood tests have revealed nothing conclusive.

Trans-vaginal scan: A small scanner is inserted into the patient’s vagina so that the uterus can be viewed close up.

Hysteroscopy: This is a small telescope that examines the inside of the uterus. During this procedure, if necessary, a biopsy can be taken of the lining of the uterus (womb).

Biopsy: A small sample of the lining of the uterus is taken and then examined under a microscope.

If the woman has no symptoms and the fibroids are not affecting her day-to-day life she may receive no treatment at all. Even women who have heavy periods and whose lives are not badly affected by this symptom may also opt for no treatment. During the menopause symptoms will usually become less apparent, or disappear altogether as the fibroids usually shrink at this stage of a woman’s life.

When treatment is necessary it may be in the form of medication or surgery.

Treating fibroids with medication:

• GnRHA (gonadotropin released hormone agonist)
• Other drugs may be used to treat fibroids; however, they are less effective for larger fibroids

Surgery to treat fibroids. When medications have not worked, the patient may have to undergo surgery. The following surgical procedures may be considered:

• Hysterectomy – removing the uterus. This is only ever considered if the fibroids are very large, or if the patient is bleeding too much. Hysterectomies are sometimes considered as an option to stop recurrences of fibroids (stop them coming back). Hysterectomies have two possible side-effects:
  1. Reduced libido
  2. Early menopause
• Myomectomy – the fibroids are surgically removed from the wall of the uterus. This option is more popular for women who want to get pregnant (as opposed to a hysterectomy). Women with large fibroids, as well as those whose fibroids are located in particular parts of the uterus may not be able to benefit from this procedure
• Endometrial ablation – this involves removing the lining of the uterus. This procedure may be used if the patient’s fibroids are near the inner surface of the uterus. This procedure is considered as an effective alternative to a hysterectomy

Menopause is defined as the absence of menstrual periods for 12 months. It is the time in a woman’s life when the function of the ovaries ceases. The average age of menopause is 51 years old, but menopause may occur as early as the 30s or as late as the 60s. There is no reliable lab test to predict when a woman will experience menopause.

Below are some symptoms that women may have around the time of menopause

• Hot Flushes
• Problems Sleeping
• Vaginal Dryness
• Mood Swings
• Memory Problems

Most women do not need treatment of menopausal symptoms. Some women find that their symptoms go away by themselves, and some women just don’t find the symptoms very uncomfortable. But if you are bothered by symptoms, there are many ways to deal with them, including medications and lifestyle changes.

You may find it hard to decide about treatment options like menopausal hormone therapy because of the possible side effects. Talk to your doctor about the possible risks and benefits so you can choose what’s best for you. No one treatment is right for all women.

When you talk about treatment options with your doctor, discuss issues like:

• Your symptoms and how much they bother you
• Your personal risks based on your age, your overall health, and your risk for diseases such as heart disease or cancer
• Whether you have used a treatment like menopausal hormone therapy (MHT) before
• Whether you have already gone through menopause and, if so, how long ago