Gynaecological Conditions

Many women experience heavy menstrual bleeding at various stages in their lives. For some, this can be a distressing condition and can interfere with everyday life. 20% of women are affected by a heavy period, which is defined as when you are losing more than 80ml of blood over the course of your period. The normal amount of blood loss is about 40ml over 3 to 7 days. Most women’s periods come every 25 to 35 days, with the average length of cycle being 28 days. This condition can cause issues such as anaemia due to iron deficiency due to increased blood loss.

There are many causes of heavy periods. Many of these are as a result of issues in the uterus. Some include:

• Polyps – which are usually a thickening of the lining of the uterus.
• Fibroids – these are thickenings in the muscle layer of the uterus.
• Endometrial hyperplasia – this is a thickening of the endometrium which causes heavy bleeding.
• Adenomyosis – this is a condition where the lining of the uterus is found embedded in the muscular layer of the uterus which again, causes heavy bleeding.
• Bleeding disorders – these include unusual conditions such as Von Willebrand’s Disease, Thrombocytopenia (low platelet count).
• Medications – that cause bleeding, such as Warfarin.

Other causes of heavy bleeding include:

• Intrauterine devices
• Thyroid disorders
• Cancer of the endometrium
• Hormone imbalance – this condition can occur if you do not ovulate. The lining of the uterus may become thickened and bleeding can become heavy or irregular. This sort of bleeding is often seen in perimenopausal women and in women just starting their periods.

Often, we order a full blood count and thyroid function tests, as well as tests for iron studies to investigate the causes of your heavy bleeding. An ultrasound of the pelvis may help pick up endometrial hyperplasia, endometrial polyps and fibroids. Sometimes we can perform a small biopsy of the lining of the uterus in the examination room at my practice to look into causes as well.

Heavy periods can be managed in a variety of ways. Initially hormone therapy and oral medications such as Tranexamic Acid are helpful. There are many minor procedures such as the insertion of a Mirena coil or an endometrial ablation, which provide great relief from heavy periods. If these lesser procedures are unsuccessful, there is still the option of undergoing a hysterectomy. Normally I perform this through a laparoscope (telescope) which means that patients are discharged from hospital with a minimum amount of pain and after only a short stay in hospital.

If you have an abnormal pap smear, this doesn’t necessarily mean that the Gardasil vaccinations you had as a teenager were ineffective. Gardasil certainly reduces the severity of the changes which may occur on the cervix. If you have abnormal cells, I often perform a colposcopy which is looking at the cervix through a pair of binoculars. This is just like having a pap smear done and is performed in my rooms. It is to sample the abnormal cells and is a very minor procedure.

Endometriosis is a common condition in which the lining of the uterus is found in areas outside the uterus. In these areas, it can cause problems with anatomical distortion, scarring, pain and problems with achieving a pregnancy. Some of the symptoms of endometriosis include pain with periods, pain before periods and pain with intercourse. We can diagnose this by putting a very fine telescope in through the patient’s navel. Often we can both identify and treat endometriosis at the same time. This surgery has proven to improve endometriosis in over 70% of cases and requires a general anaesthetic. Endometriosis can be continually suppressed by using medications such as the oral contraceptive, the Mirena intrauterine contraceptive device or a short course of medications called G.N.R.H. analogues. The main reason Endometriosis causes problems is because it has a negative effect both on eggs, embryos and implantation – but the good news is that with the above treatments and management women can often achieve pregnancy.

An ovarian cyst is a fluid filled sac on the surface or on the inside of the ovaries and are relatively common. A small (functional) cyst occurs every month when the egg grows inside the follicle of the ovary. Normally the egg is released and the follicle collapses, but sometimes the egg isn’t released and a small cyst occurs. Usually speaking, a small cyst doesn’t need to be treated, however cysts occurring after menopause are different and may need further investigation. Most of the time ovarian cysts cause no symptoms, however they can undergo a complication which may involve bleeding, rupture, and pain with intercourse or even torsion – where the ovary twists around and obstructs its own blood supply. Symptoms may include low abdominal swelling, pain with intercourse and pain with bowel movements. If the pain is very severe and is associated with nausea and vomiting this could indicate torsion of the ovary. Urgent medical advice should be sought in this case.

Tests for ovarian cysts
If your cysts are functional (physiological cysts) there is little need to undergo further investigations than ultrasound. Other investigations include CA125 and HE4 which are both tests for ovarian cancer. Sometimes other tests such as HCG, estradiol, FSH, LH or testosterone could be required.

Treatment
Within two months most functional cysts have disappeared. One treatment that we commonly use is the oral contraceptive, which is often useful in reducing the appearance of new cysts. If they are persistent, more than 5 cm in diameter, causing pain, or are complex in structure, surgery may be required to remove them. This is often done through a telescope but can involve an open operation such as a laparotomy.

Fibroids are thickenings in the muscles of the uterus (womb). They are generally benign and there is only a small risk of them becoming cancerous. Up to 70% of the population experience fibroids with most reporting symptoms like heavy periods and occasionally a feeling of pressure in the abdomen. They may cause pressure on the bowel or bladder leading to urinary frequency and sometimes constipation. Depending on where the fibroids are located they can pose a problem in pregnancy. To find out about the size and location of any fibroids you may have we usually do a physical examination and ultrasound.

Treatments
If the fibroids are causing fertility problems we can shrink them down using a number of medications including GnRH analogues (e.g. Zoladex). A newer group of drugs called SPRMS (eg. Ulipristal) are very useful in shrinking fibroids and have fewer side effects than GnRH analogues. As yet it is not on the subsidised drug list (PBS). If the problem is mainly heavy periods, Tranexamic Acid or anti-inflammatories such as Ibuprofen or Mefenamic Acid may reduce cramps and lighten periods.

Surgery
Fibroids can be removed through a small telescope, a laparoscope if they are outside the uterus (womb) or if they are inside the uterus (womb) through another telescope called a hysteroscope. There are other techniques such as MRI focused ultrasound or uterine artery embolization which may have a place in shrinking fibroids. For women who don’t wish to have any future pregnancies we may consider performing a hysterectomy. This can often be done through a telescope, meaning that the hospital stays are considerably reduced and early return to work is made more likely.

A prolapse occurs when structures in the pelvis such as the uterus, bladder or bowel fall from their correct position because their support structures have become weakened. You may notice a lump or a bulge in the pelvis and it is much more common in women who have had children (particularly vaginal births) and also if those labours were difficult. Prolapse is more common after menopause and is usually worsened by things such as obesity, chronic cough, constipation and straining when going to the toilet. Other factors that can contribute are things like heavy lifting or smoking. Prolapse can affect the bladder, bowel or the uterus, and we can usually assess this during a consultation. There are a number of treatments; I recommend pelvic floor physiotherapy to strengthen up the muscles in the pelvis which can prevent your prolapse from worsening or vaginal oestrogens which can help. In some cases a ring pessary, which is a white PVC circular object, can be inserted into the vagina. The pessary can help to hold the prolapse up and will need to be changed every six months.

Surgery for prolapse
There are a variety of surgical techniques that we can perform to support the prolapsed pelvic tissue. Most of the time we can do minor procedures through the vagina – and these are generally very successful. Unfortunately, over time, particularly if the cause of prolapse persists, a further prolapse may occur. If you have any concerns it’s important that you let me know.

At least 10% of women have bladder control problems. The first step is usually to undergo intensive pelvic floor exercises with a physiotherapist. If this isn’t helping we might have to investigate a bit further. Sometimes this involves a technique called urodynamics (meaning bladder function) which is a procedure performed in hospital. A treatment that we often use is an oral medication which helps to improve your bladder control. Sometimes a minor operation called a sling procedure is needed, which works to restore good bladder control.