Gynaecology

What is endometriosis?

Endometriosis is a common gynaecological problem affecting women of reproductive age. It occurs when the tissues of the uterus start growing on surfaces of other organs in the pelvis. Endometrium may grow on ovaries, fallopian tubes, outer surface of uterus, pelvic cavity lining, vagina, cervix, vulva, bladder or rectum. Patients may experience painful cramps in the lower abdomen, back or in the pelvis during menstruation, heavy menstrual bleeding, painful bowel movements or urination and infertility.

What are the causes for endometriosis?

The exact cause for endometriosis is not known, but it is thought to be inherited through genes that run-in families. A defect in the immune system, hormonal imbalance, or a complication of other surgeries may cause women to develop endometriosis.

How is endometriosis diagnosed?

Your gynaecologist will ask you about your general health, your symptoms and perform a pelvic examination to feel for the presence of large cysts or scars. An ultrasound scan may also be performed to look for ovarian cysts.

What are the treatment options?

There are several treatment options available to minimize the pain as well as control heavy bleeding.

Pain Medication: Over the counter pain relievers may be helpful for mild pain. Nonsteroidal anti-inflammatory medications will be prescribed by your doctor in cases of severe pain.

Hormone Treatment: Hormone treatment is recommended if there is a small growth and mild pain. Hormonal preparations can be taken in the form of pills, shots, and nasal sprays. Birth control pills help to decrease the amount of menstrual bleeding.

Surgery: Surgery is an option for women having multiple growths, severe pain, or fertility problems. Options include:

• Laparoscopy: During this surgery, growths and scar tissue are removed or cauterized. This is a minimally invasive technique and does not harm the healthy tissues around the growth.
• Laparotomy or major abdominal surgery: This involves a larger cut in the abdomen which allows the doctor to reach and remove the endometrial growth.
• Hysterectomy: It is a surgery that involves removal of the uterus. This procedure is done when there is severe damage to the uterus and only if patient does not want to become pregnant in the future.

What is contraception?

Contraception, also known as birth control practice is prevention of pregnancy by interfering with the process of conception and implantation. Numerous methods of contraception are in practice and include barrier or hormonal methods, withdrawal, natural family planning, abstinence, and sterilization (surgery). Some of these methods are confined for women and others for men, while some of the methods are reversible and some are permanent methods.

What are the various methods of contraception?

• Abstinence: Abstinence means not having sexual intercourse. It is the only birth control method that is 100% effective in preventing pregnancy as well as sexually transmitted diseases.
• Natural family planning method: Natural family planning (NFP) or fertility awareness does not require medication, physical devices, or surgery to prevent pregnancy. This method relies on the woman's body physiology to know the time of ovulation. This method involves monitoring different body changes such as basal body temperature or cervical mucus variations. The woman then abstains from unprotected sex for approximately 7 to 10 days when she may have ovulated.
• Barrier methods: It is one of the most common contraceptive methods and involves forming a physical barrier to obstruct the sperm from entering a woman's uterus. Barrier methods include use of male condom, female condom, spermicides, diaphragm, cervical cap, and contraceptive sponge. The male condom is a thin covering made of latex or polyurethane that is rolled over an erect penis before sexual intercourse to prevent the sperm from entering a woman's vagina. The female condom is a polyurethane (plastic) tube that has a flexible ring at each end and is inserted into the vagina before sexual intercourse. Spermicides are chemicals that inactivate or kill sperm and are available as foams, suppositories, and jellies. A diaphragm is a flexible dome that covers the cervix inside the vagina. The cervical cap is a smaller cup made of latex rubber or plastic. These should be used in conjunction with a spermicidal gel and are placed in the vagina before sexual intercourse. The sponge is a soft, round barrier device made of polyurethane foam.
• Hormonal methods: In this method, synthetic hormonal preparations containing oestrogen and progesterone will be taken orally (pills), implanted into body tissue (implants), injected under the skin (injections), absorbed from a patch on the skin (skin patches), or placed in the vagina (vaginal rings). These methods work by preventing ovaries from releasing an egg for fertilisation. The intrauterine device (IUD) is a small device made of copper that is inserted into the uterus. It works by thickening the mucus around the cervix and by thinning the womb's lining, making it difficult to accept a fertilised egg.
• Withdrawal: Withdrawal method involves the complete removal of the penis from the woman's vagina before ejaculation.
• Sterilisation: This method is a permanent solution and is meant for men and women who do not intend to have children in the future. Male sterilisation involves vasectomy, a surgical blocking of the vas deferens, the tubes through which sperm pass into the semen. Female sterilisation involves a tubal ligation, a surgical procedure that blocks the fallopian tubes which carry the eggs from the ovaries to the uterus.

The choice of a method of contraceptive depends on an individual's age, health, frequency of sexual activity, number of sexual partners, plans for future pregnancy, and certain medical conditions. Discuss with your doctor about the choices of birth control available for your situation.

What are fibroids?

Uterine fibroids are non-cancerous (benign) tumours, commonly seen in women of childbearing age. Fibroids are composed of muscle cells and other tissues. They develop in and around the wall of the uterus or womb. Uterine fibroids are usually round or semi-round in shape.

What are the different types of fibroids?

Based on their location within the uterus, uterine fibroids can be classified as:

• Subserosal fibroids: Sited beneath the serosa (the membrane covering the outer surface of the uterus)
• Submucosal fibroids: Sited inside the uterine cavity below the inside layer of the uterus
• Intramural fibroids: Sited within the muscular wall of the uterus
• Intracavitary fibroids: Sited inside the uterine cavity
• Pedunculated fibroids: Develop on a stalk attached to the outer wall of the uterus

What are the causes of fibroids?

The exact cause for the development of fibroids remains unknown, but some of the proposed causes include:

• Genetic abnormalities
• Alterations in expression of growth factor (protein involved in rate and extent of cell proliferation)
• Abnormalities in the vascular system
• Tissue response to injury
• Family history of fibroids
• Uterine infection
• Consumption of alcohol
• Elevated blood pressure
• Hormonal imbalance during puberty

What are the symptoms of fibroids?

Most women with uterine fibroids may be asymptomatic. However, the basic symptoms associated with fibroids include:

• Heavy menstrual bleeding
• Prolonged menstrual periods
• Pelvic pressure or pain
• Frequent urination
• Constipation
• Backache or leg pain
• Difficulty in emptying your bladder

How are fibroids diagnosed?

The diagnosis of uterine fibroids involves a pelvic examination, followed by ultrasound evaluation. Other imaging techniques such as MRI scan and CT scan may also be employed.

What are the treatment options?

Different methods are being used for managing uterine fibroids. Surgery is considered the best modality of treatment. The common surgeries performed for the management of fibroids include:

• Hysterectomy or removal of the uterus
• Myomectomy or selective removal of the fibroids within the uterus
• Destructive techniques that involve boring holes into the fibroids with a laser or freezing probes (cryosurgery)
• Other techniques employed are uterine artery embolization (UAE) and uterine artery occlusion (UAO)

Non-surgical methods comprising of steroidal medication are also used to stabilize the estrogen levels in the body.

What are the risks caused due to fibroids during pregnancy?

Some studies indicate that the presence of uterine fibroids during pregnancy increases the risk of complications such as first trimester bleeding, breech presentation, placental abruption, increased chance of caesarean section and problems during labour.

The inability of women to conceive after a year of having unprotected sex, or the inability of women to sustain pregnancy is known as infertility.

When to get help?

You may have reason to be concerned if you have been trying to get pregnant for at least one year and:

• You are in your late 30s and have been trying to get pregnant for six months or longer
• Your menstrual cycles are either irregular or absent
• You have painful periods
• You have a known history of fertility problems
• You have a history of pelvic inflammatory disease or endometriosis
• You have had multiple miscarriages
• You have been treated for cancer with drugs and radiation

What are the causes?

Infertility can be present from birth (congenital) or can be acquired as you age. Some of the causes may include:

Problems with ovulation: Certain conditions, like polycystic ovarian syndrome (ovaries secrete excessive amounts of male hormone testosterone) and hyperprolactinemia (produce high amounts of prolactin, a hormone that induces the production of breast milk), can prevent your ovaries from releasing eggs.

Damaged fallopian tubes: Fallopian tubes carry the eggs from the ovaries to the uterus. Any damage to them can affect the fertilization of the egg by the sperm. Pelvic surgeries and infections can cause formation of scar tissue that can damage your fallopian tubes.

Abnormalities of the cervix and uterus: Abnormal mucus production in the cervix, problems with the cervical opening, abnormal shape and presence of benign tumours in the uterus can all contribute to infertility.

Premature menopause: Mostly caused by a condition known as primary ovarian insufficiency, premature menopause occurs when menstruation stops before the age of 40. The exact cause of this condition is unknown, though various treatments for cancer and abnormalities with the immune system have been known to contribute to it.

Adhesions: Bands of scar tissue can form in the pelvis after an infection or surgery.

Other medical conditions: Diabetes, endometriosis, thyroid disorders, sickle cell disease or kidney diseases can affect the fertility of a woman.

Medications: Certain medications have been known to cause temporary infertility. Stoppage of those medications can restore fertility in most of the cases.

Who is at risk?

Your risk for infertility increases with age. You are at a greater risk if you smoke, consume excess alcohol, or are overweight, obese, or underweight.

How is infertility diagnosed?

Female infertility can be confirmed with the following tests:

Blood tests measure your hormone levels and determine if you are ovulating.

Biopsies may be obtained to evaluate the inner lining of your uterus.

Ovarian reserve testing may be performed to determine the number and quality of eggs ready for ovulation.

Imaging studies such as a pelvic ultrasound or hysterosonography may be performed to obtain a detailed view of your fallopian tubes and uterus.

Hysterosalpingography involves obtaining an x-ray image after injecting a contrast material into your cervix which travels up to your fallopian tubes. This can help identify any blockages in your fallopian tubes.

Laparoscopic evaluation involves inserting a thin tube fitted with a camera through an incision in your abdomen, to detect any abnormalities in your reproductive organs, such as the ovaries, uterus, and fallopian tubes.

How is infertility treated?

Your doctor will suggest a treatment suitable for your problem. Fertility drugs may be recommended to stimulate and regulate ovulation, in women who are infertile due to ovarian disorders. You could also be chosen for assisted insemination, where healthy sperm is collected, concentrated, and placed directly into your uterus, when your ovary releases eggs to be fertilized. This procedure is also known as intrauterine insemination (IUI), and can be in tandem with your normal menstrual cycle or fertility drugs. Apart from these, problems with your uterus, such as intrauterine polyps or scar tissue, can be treated with surgery.

In vitro fertilization (IVF) is a type of assisted reproductive technique, which involves collecting multiple mature eggs from a woman and fertilizing them with sperm outside the body, in the lab. Once fertilized, the embryos are implanted into the uterus within three to five days.

Some of the other techniques used in IVF include intracytoplasmic sperm injection (a single healthy sperm cell is directly injected into a mature egg), assisted hatching (the outer covering of the embryo is removed to facilitate embryo implantation into the uterus), and using donor eggs or sperm. Gestational surrogates may also be considered for women for whom pregnancy poses high health risks, or for those who have a non-functional uterus.

What is vaginal prolapse?

A prolapse is a medical condition where an organ or tissue falls or slips from its normal position. A pelvic organ prolapse is a condition that occurs when the structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself falls out from their normal position.

Utero-vaginal prolapse is a downward movement of the uterus and/or vagina. The main cause of the prolapse is the weakness in the supporting tissues of the uterus and vagina. The common factors such as frequent lifting of heavy objects, chronic cough, severe constipation, menopause, childbirth, and pregnancy may increase your risk of developing utero-vaginal prolapse.

What are the symptoms of prolapse?

A woman with a mild prolapse may not experience any symptoms. However, women with more severe forms of prolapse may experience:

• Sensation of pulling in the lower abdomen or pelvis
• An uncomfortable feeling of fullness in the vagina
• Low back pain
• Urinary problems, such as urine leakage or urine retention
• Difficulty in urinating and emptying bowel
• Vaginal bleeding or discharge

How is vaginal prolapse diagnosed?

Your doctor will diagnose the condition by taking a detailed history and performing a physical examination. During the examination, you may be asked to cough or bear down. The doctor may also perform computerised testing of the bladder to test for urinary leakage.

What are the treatment options?

If the symptoms are mild, non-surgical treatment options such as medications, pelvic floor exercises, vaginal pessary (a device that is inserted into the vagina to support the pelvic floor), estrogen containing vaginal cream, and lifestyle changes may be helpful.

Surgery can be considered in patients with severe symptoms of utero-vaginal prolapse. There are different types of procedures to address the prolapse, such as hysterectomy (removal of the uterus), hitching up the bladder or vagina, or repair and 'tightening' of the vagina. The surgery may be done through an incision in either the abdomen or the vagina, depending upon the condition. The aim of the surgery is to restore normal anatomy and function of the pelvic organs.

What are the complications involved?

If left untreated, severe cases of utero-vaginal prolapse can cause ulceration and infection of the cervix and vaginal walls, urinary tract infections, lower tract bleeding, thickening of the skin of the cervix, urinary obstruction, and worsening of the prolapse.

How can vaginal prolapse be prevented?

Although utero-vaginal prolapse is not always preventable, there are certain measures that can be taken to help reduce the risk of developing utero-vaginal prolapse or prevent it from getting worse. These include:

• Perform Kegel exercises to strengthen your pelvic floor muscles especially during pregnancy and after childbirth
• Do not bear down when giving birth until your cervix is completely dilated
• Take hormone replacement therapy after menopause
• Avoid constipation and straining with bowel movements, after delivery
• Avoid heavy lifting, prolonged standing, and chronic cough
• Perform pelvic floor exercises on a regular basis

What is menorrhagia?

Menorrhagia is a condition characterized by abnormally heavy or extended menstrual bleeding. With menorrhagia, you may have excessive blood loss and pain that disturbs your normal activities.

What are the symptoms of menorrhagia?

The most common symptoms of menorrhagia are:

• Menstrual flow that soaks one or more pads per hour for several consecutive hours
• The need to use double sanitary protection to control the flow of blood
• Need to change your pad frequently during the night
• Menstrual period that lasts longer than seven days
• Menstrual flow that includes large blood clots
• Affects daily routine activities due to heavy menstrual flow
• Fatigue, weakness or shortness of breath (symptoms of anaemia)

What are the causes of menorrhagia?

The cause of menorrhagia is not known in some cases; however several conditions that may cause menorrhagia include hormonal imbalance, dysfunction of the ovaries, uterine fibroids(noncancerous (benign) tumours of the uterus), uterine polyps, adenomyosis (where endometrial glands are found in the muscular wall of the uterus), intrauterine devices (IUDs), pregnancy complications, cancer, inherited blood disorders, certain medications (anti-inflammatory medications and anticoagulants), and other medical conditions such as pelvic inflammatory disease (PID), thyroid problems, endometriosis, and liver or kidney disease.

How is menorrhagia diagnosed?

Your doctor will perform a pelvic examination and may recommend other tests or procedures such as a pelvic ultrasound scan or a biopsy of the lining of the womb if the woman is over 40 years of age. Biopsy is a technique of removing a piece of tissue from the inner lining of the uterus which is examined under a microscope. This is done to make sure that the cells are growing normally. Your doctor may also recommend an examination called hysteroscopy, which involves placing a tiny tube with a light through your cervix to obtain a direct view of the lining of the womb.

What are the treatment options?

Treatment options will depend on the cause of menorrhagia, the severity of menorrhagia and the overall health of the patient. Some common treatments include:

• Iron supplements may be started if your iron levels are low.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) may help reduce menstrual blood flow as well as cramping.
• Oral contraceptives may be given to help reduce bleeding and make menstrual cycles more regular.
• Oral progesterone may be given to help correct hormonal imbalance and reduce menorrhagia.

• Mirena, a type of intrauterine device, releases progestin in the womb that thins the uterine lining and reduces the blood flow.

Surgery may be needed if medication therapy is not successful. The surgical procedures include:

• Endometrial ablation: It is a procedure that permanently destroys the entire lining of your uterus (endometrium) resulting in little or no menstrual flow.
• Dilation and curettage (D&C): It is a procedure in which the cervix is dilated and the lining of the uterus is scraped to reduce menstrual bleeding. You may need additional D&C procedures if menorrhagia recurs.
• Hysterectomy: It is a surgical removal of the uterus and the cervix that leads to infertility and the cessation of menstrual periods.
• Hysteroscopy: This procedure involves the use of a hysteroscope, a tiny tube with a light to view your uterine cavity and to remove abnormalities such as polyps that may be causing heavy menstrual bleeding.
• Endometrial Resection: It is a surgical procedure that uses an electrosurgical wire loop to remove the lining of the uterus.

Hysterectomy, endometrial ablation, and endometrial resection procedures may reduce your ability to become pregnant. Therefore, discuss with your doctor about the treatment options if you plan to become pregnant in the future.

Hirsutism and Menstrual Disorders

Menstrual disorders are a set of problems that affect a woman's monthly menstrual cycle (monthly bleeding). They include no menstruation (amenorrhoea), light or irregular periods (oligomenorrhoea), heavy periods (menorrhagia) and painful periods (dysmenorrhoea).

Hirsutism is a condition characterised by the excessive growth of body or facial hair in women, much like hair growth patterns seen in men. The hair grows thick and dark on the face (resembling a moustache and beard), chest, back, upper arms, lower stomach, around the nipples and legs. Hirsutism may be related to menstrual disorders.

What are the causes?

Hormones play an important role in regulating growth and other bodily functions. At the onset of puberty, a mixture of female and male sex hormones is produced for sexual maturity. An imbalance in these hormones or increased production of male hormones can lead to hirsutism (high levels of the male sex hormone androgen) and menstrual disorders. The recent increase in childhood and adolescent obesity is also a major factor that has led to the high incidence of hirsutism and menstrual disorders. Other causes may include:

Menstrual disorders

• Dysmenorrhea may occur due to endometriosis (chronic condition where the uterine lining grows over the ovaries and bladder) or fibroids (noncancerous growth on the walls of the uterus), cyst in the ovaries and the use of intrauterine contraceptive devices (IUDs).
• Menorrhagia may be caused due to uterine fibroids, problems in ovulation (release of fully developed ovarian cells), endometriosis, uterine polyps (small benign growth), cancer, severe infection, miscarriage or ectopic pregnancy (pregnancy outside the womb), certain medication and IUDs.
• Oligomenorrhea may develop due to polycystic ovary syndrome (ovarian cysts), weight loss, endometriosis, stress and medications.

Hirsutism

• Polycystic ovary syndrome
• Cushing's syndrome (high levels of cortisol, a steroid hormone)
• Congenital adrenal hyperplasia (an inherited condition characterised by abnormal levels of cortisol and androgen)
• Tumour (tumour in adrenal gland or ovaries)
• Certain medications

What are the symptoms associated with these conditions?

Symptoms associated with menstrual disorders are:

• Irregular periods
• Lower back pain
• Sense of burning during urination
• Infertility (difficulty getting pregnant)
• Fever
• Abdominal cramps
• Unusual vaginal discharge

The symptoms of hirsutism include:

• Acne
• Balding
• Deepening voice
• Reduced breast size
• Enlargement of clitoris

How are the conditions diagnosed?

Your doctor will collect your medical history to understand the reason behind your condition. You may be ordered blood tests to evaluate the variation in the levels of hormone. A high level of the male hormone testosterone in blood confirms hirsutism. An ultrasound examination or CT scan may be ordered to examine the presence of cysts, fibroids or tumours in your ovaries. Laparoscopic examination and biopsy may be performed to diagnose cancer.

What are the treatment options?

Your doctor may prescribe hormone therapy or oral contraceptive pills to treat menstrual disorders and hirsutism. Surgical procedures may include the removal of fibroids, cysts or tumours. Surgery may be recommended only in cases of severe menstrual disorders. Other cosmetic procedures, such as electrolysis (mild current targeted at hair follicles) and laser therapy (laser beam targeted over skin to destroy hair follicles), and temporary hair removal procedures (waxing, shaving, etc.) may help control the excessive growth of hair.

What is an ovarian cyst?

An ovarian cyst is a fluid filled sac or pouch which forms on the ovary. Ovarian cysts, in most cases are harmless and resolve on their own. If the cyst is cancerous, it may cause problems and thus needs medical intervention. Ovarian cysts are common in women of childbearing age.

What are the symptoms?

Ovarian cysts are symptomless most of the time but may cause variable abdominal or pelvic pain or pain during intercourse. If the cyst is large, it may cause twisting of the ovary that leads to pain.

How are ovarian cysts diagnosed?

Ovarian cysts may be diagnosed during a routine pelvic examination, such as a Pap smear. Your doctor may recommend tests such as vaginal ultrasound, CT or MRI scan. If you are a menopausal woman, then in addition to ultrasound your gynaecologist may order blood tests to measure tumour markers (substances produced by certain types of cysts) which give useful information in the diagnosis and prognosis.

What are the treatment options?

Most ovarian cysts will resolve on their own without any treatment. Birth control pills may be prescribed to reduce the formation of new ovarian cysts. Surgery to remove the cyst is an option if the cyst does not go away, is larger in size, or causes pain. Cystectomy is a surgical excision of an ovarian cyst.

How is cystectomy done?

Cystectomy is a surgical procedure during which the ovarian cyst is removed either using laparoscopy or an open surgery approach. A laparoscopic cystectomy procedure is a minimally invasive surgery during which a laparoscope, a long thin instrument with a camera attached at one end is used. The procedure is usually done under general anaesthesia and a small incision is made below the navel. A laparoscope is inserted through this incision to see the inside of your pelvis and abdomen. Carbon dioxide gas is introduced into the abdominal cavity to create more space to work. Your surgeon identifies the cyst through the scope and removes the cyst. This technique is usually used to remove small cysts.

A laparoscopic cystectomy removes only the cyst leaving the ovaries intact. However, if the cyst is too large or connected to ovarian tissue, your surgeon removes all or part of the ovary.

What should I expect after this procedure?

Following ovarian cyst removal, complete recovery usually takes about one to two weeks. Your doctor may prescribe anti-inflammatory medications to help relieve your pain. The ovaries return to normal function after a cystectomy is performed.

What is PCOS?

Polycystic ovarian syndrome is a hormonal imbalance which is quite common, affecting 5%-10% of women. A syndrome is a group of symptoms/findings that are seen together. In PCOS, these include chronic absence of ovulation, chronic elevated testosterone levels, and ovaries with multiple small cysts (polycystic) containing eggs. To qualify as PCOS, 2-3 of these findings must be present

How does your doctor diagnose PCOS?

Diagnosis of PCOS is accomplished by identifying the different symptoms/findings through a history and physical examination, ultrasound imaging study and blood tests.

Women with PCOS usually have a history of irregular or missed periods and long duration between periods. They may be unable to get pregnant and have increased acne and hair growth (hirsutism). Enlarged ovaries with multiple cysts characterize PCOS on the ultrasound. Blood tests reveal elevated levels of sugar, cholesterol and male hormones.

What are the risks associated with PCOS?

Not ovulating regularly carries certain risks. It causes elevation of estrogen which leads to excessive thickening and abnormal bleeding of the lining of the uterus. Over time, precancerous changes or uterine cancer may develop. Irregular ovulation can also make conception difficult.

Women with PCOS commonly have metabolic syndrome which includes fat accumulation around the waist, hypertension, elevated cholesterol and insulin resistance or diabetes. Obesity is also common. These symptoms increase the risk of heart disease.

How do you treat infertility in women with PCOS?

Medication may be prescribed to induce ovulation. These include Clomiphene citrate and Letrozole which are oral medications. Letrozole is particularly helpful and usually tried first. If these fail, fertility medicines called gonadotropins may be injected to stimulate egg growth. Care is taken while administering these medications as they can sometimes cause multiple births.

Overweight women are advised to lose weight which can improve the pattern of ovulation and fertility.

Some patients with PCOS may be helped by medications such as metformin which helps the body use insulin more effectively. The risk of developing diabetes and metabolic syndrome may also be lowered by metformin.

If the above treatments are unsuccessful, in vitro fertilization (IVF) is recommended.

How do you treat PCOS in women who are not trying to conceive?

Hormone medications are usually prescribed to treat women with PCOS when pregnancy is not the goal. Excessive hair growth and acne can be controlled by oral contraceptive pills. These also regulate the menstrual periods, preventing pregnancy and reducing the risk of cancer. The risk of developing diabetes and metabolic syndrome may be lowered by taking metformin.

Medications that specifically lower male hormones can help with excessive acne and hair growth. Excess hair growth can also be managed by laser treatment and electrolysis. Weight loss is recommended as it has been found to lower male hormone levels and the risk of developing diabetes.

PCOS can present differently in different women and changes may occur over time. Your doctor will recommend and modify treatment according to your situation.

What is PMB?

Bleeding after menopause, also known as post-menopausal bleeding (PMB), is a condition characterized by vaginal bleeding after 12 months of menopause. PMB is not pertinent to young women having amenorrhoea (absence of menstrual periods) due to anorexia nervosa or having a pregnancy followed by lactation. PMB may be related to those young women who are suffering from premature ovarian failure or premature menopause.

Menopause is a natural biological process resulting in a permanent cessation of menstruation. Menopause usually occurs in women during the fifth decade of their life. Menopause is confirmed by an absence of menstrual periods for 12 months consecutively.

In most cases, PMB is harmless, but sometimes it may be secondary to an underlying medical disorder. Therefore, bleeding after menopause should be carefully investigated.

What are the causes of PMB?

The common causes of post-menopausal bleeding include:

• Thinning of the tissues lining the uterus (endometrial atrophy) or vagina (vaginal atrophy)
• Uterine fibroids
• Cervical and endometrial polyps
• Infection and inflammation of the uterine lining (endometritis)
• Endometrial hyperplasia
• Medications such as hormone replacement therapy
• Cancer of the uterus, including endometrial cancer and uterine sarcoma
• Cancer of the cervix or vagina
• Non-gynaecological causes such as pelvic trauma or bleeding disorder
• Bleeding from the urinary tract or rectum

How are the causes of PMB determined?

The cause of PMB can be determined by physical examination, medical history, and additional laboratory tests. The common tests that are employed are as follow:

• Transvaginal ultrasound: A specially designed imaging device is inserted through the vagina to view the pelvic organs and to identify any abnormalities.
• Endometrial biopsy: This procedure involves the insertion of a thin tube inside the uterus for withdrawing the samples of uterine lining, for laboratory analysis.
• Hysteroscopy: It involves the examination of the uterus through an instrument with a small camera and with a light source.
• D&C (dilation and curettage): This test involves the removal of tissues from the uterine lining to be sent for laboratory analysis.

What are the treatment options?

Treatment of the PMB depends on the underlying cause of bleeding. Management of some of the common causes of PMB is as follow:

• Polyps: They are surgically removed
• Endometrial atrophy: Treated with medications
• Endometrial hyperplasia: Treated with medications and/or thickened areas of the endometrium are surgically removed
• Endometrial cancer: Treatment involves total hysterectomy i.e. surgical removal of uterus and cervix. In some cases, other organs such as ovaries, fallopian tubes, nearby lymph nodes, and part of vagina may also be removed.

The treatment of advanced endometrial cancer may include hormone therapy, chemotherapy, and radiation therapy. Early detection and treatment of the cancer can result in full recovery.

Coming Soon

Women have their own health issues due to a complex reproductive system that makes them unique from men. A variety of diseases such as heart attack, depression, anxiety, sexually transmitted diseases (STD), osteoarthritis, and urinary tract problems can affect women more severely than men. These problems necessitate them to visit their doctor in timely intervals to screen for various diseases. Screening tests can assess the risk for future illnesses and help in their early detection.

What are the Common Tests for Women's Health and Screening?

Blood Pressure Check

Women with blood pressure between 120-139/80-89 or higher should have their blood pressure checked at least every year. Women with diabetes, heart disease, kidney problems, or other related conditions also need to have their blood pressure checked regularly.

Cholesterol Screening

Women at risk for heart disease need to be screened between the ages of 20 and 45. Women aged 44 and above need to be screened every 5 years. Women with diabetes, heart disease, kidney problems, or other conditions need to have their cholesterol levels checked more frequently.

Diabetes Screening

Women aged 45 or above should get tested for diabetes every 3 years. Women with blood pressure above 135/80 will be recommended by their health care provider to check their blood sugar for diabetes.

Colon Cancer Screening

Women between the ages of 50 and 75, need to be screened for colon cancer. A stool test is recommended every year. A flexible sigmoidoscopy and barium enema is recommended every 5 years. A colonoscopy is recommended every 10 years. Additional studies may be scheduled by your doctor if you have a history of ulcerative colitis or any family history of colon cancer.

Dental Examination

A dental exam and cleaning is recommended at least once in a year.

Eye Examination

An eye examination is recommended every two years for women older than 45 or with vision abnormalities. You may need to be checked for glaucoma once you cross the age of 45.

Immunisations

A flu vaccine is recommended once a year. Women after the age of 19 should have a tetanus-diphtheria and acellular pertussis (TdAP) vaccine and a tetanus-diphtheria booster every 10 years. Human papilloma virus (HPV) vaccination is recommended for women between the ages of 18 and 26. Women born after 1980, who have never had chickenpox, should receive two doses of varicella vaccine. Other vaccinations will be recommended by your health care provider if you are found to be at high risk for other diseases, such as pneumonia and shingles.

Physical Examination

At least two physical exams are recommended in your 20s. Your height, weight, and body mass index (BMI) will be checked during each examination. Women over the age of 40 should undergo a physical examination once every 5 years.

Breast Examination

Women should perform a monthly self-exam of their breasts. Any lumps or other abnormalities noted in the breasts should immediately be reported to the doctor. Women between the ages of 20 to 40 need to have their breasts examined by a doctor once every 3 years, and a complete breast exam is recommended every year in women aged 40 and above. Depending on their risk factors for breast cancer, women over the age of 40 need to have a mammogram performed everyone to two years.

Bone Density

A bone density test should be performed in all postmenopausal women with fractures. Women under the age of 65, depending on their risk factors need to be screened for osteoporosis.

Pap Smear and Pelvic Examination

Screening should begin within 3 years after the first vaginal intercourse or by the age of 21. After the age of 21, women should have both a Pap smear and a pelvic exam performed every 2 years to check for cervical cancer. Women over age 30 or whose Pap smears have been negative three times in a row may only need a Pap smear once every 3 years. Women who are sexually active should be screened for sexually transmitted diseases.

What is abnormal uterine bleeding?

Abnormal uterine bleeding, also known as Dysfunctional uterine bleeding is irregular bleeding from the uterus other than normal periods. Uterus, also referred to as the womb, is where a baby grows inside their mother.

Bleeding (spotting) between periods, after sex, heavy bleeding which lasts for more than 7 days in the menstrual cycle, and bleeding after menopause are the various modes of abnormal bleeding.

What are the causes of abnormal uterine bleeding?

Causes of abnormal uterine bleeding include:

• Pregnancy
• Fibroid tumours
• Endometrial/uterine polyp or cancer
• Hormonal imbalance (estrogen and progesterone) that happens most often in women nearing menopause or after menopause
• Miscarriage
• Ectopic pregnancy
• Polycystic ovarian syndrome (PCOS)
• Cancer of the cervix or vagina
• Use of birth control measures such as oral pills or intrauterine device (IUD)

Abnormal uterine bleeding can occur at any age in a women's life.

How is abnormal uterine bleeding diagnosed?

Your doctor will diagnose the condition by performing physical examination, including pelvic exam and taking a medical and family history. They may order a few tests to rule out other causes of abnormal bleeding. These tests include:

• Pregnancy test: To confirm whether you are pregnant.
• Blood count: To rule out blood disorders.
• Pelvic ultrasound: It is an advanced imaging test that uses high-frequency sound waves to create pictures of the female pelvic organs (uterus and ovaries).
• Endometrial biopsy: It is a procedure that involves sampling of the cells lining the uterus (endometrium) for any abnormalities.
• Hysteroscopy is a minor and safe surgical procedure used for diagnosis and/or treatment of various conditions of the uterus. In this procedure, a thin magnifying instrument called hysteroscope is inserted into the uterus through the vagina to view the internal structures for diagnosing or treating the conditions. The camera in the hysteroscope displays the images on to the monitor thereby helping the surgeon to view the internal structures.

What are the treatment options?

The treatment plan depends on several factors such as your age, cause of bleeding, and whether you are planning to become pregnant. The treatment options include:

• Birth control pills help to maintain regular periods.
• IUD that releases hormones: IUD is a birth control device that is inserted in the uterus. Abnormal bleeding may be controlled through the release of hormones.
• Dilatation and curettage (D & C) is a surgical procedure in which the cervix is expanded with a dilator and the tissue lining the uterus (endometrium) is scraped with a curette.
• Hysterectomy is the surgical removal of the entire uterus. This procedure will stop periods and is not suggested in women who desire to have children.
• Endometrial ablation: A procedure in which the tissue lining the uterus is destroyed by various ablation techniques such as laser beam, freezing, or heating.

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What is menopause?

Every woman goes through several changes in the way her body functions, which marks different stages in her life. With puberty, starts the menstrual cycle, where certain hormones control the monthly release of the egg and preparation for pregnancy. The termination of menstruation and fertility of women is known as menopause, and occurs 12 months after your last menstrual period, when you are in your 40s or 50s. Some women can experience menopause before their 40s, and the condition is known as premature menopause.

What are the symptoms of menopause?

Menopause can be characterized by physical and emotional changes. Approaching the time of your menopause (perimenopause), you may experience irregular menses, dryness of the vagina, sagging of the breasts, dry skin, thinning hair, slow metabolism, weight gain, hot flashes, night sweats, problems with sleeping, and mood changes.

What are the causes of menopause?

Menopause is a natural process that takes place in every woman's like as you reach your early 40s or 50's. The production of the hormones by your ovaries to regulate your menstrual cycle, namely oestrogen and progesterone, start to decrease. Eventually, your ovaries will stop producing eggs. This will make you experience changes in your menstrual pattern and bring an end to your periods.

There are some factors that can induce menopause. These include the following:

Cancer treatment: Chemotherapy (treatment with chemical agents) and radiotherapy (treatment by exposure to radiation) can cause menopause symptoms, and a temporary or permanent stop to your menstruation.

Failure of ovaries: Autoimmune diseases or genetic factors can cause your ovaries to produce less than normal amounts of reproductive hormones. This is known as primary ovarian insufficiency, and can lead to premature menopause.

Surgeries: Surgeries such as total hysterectomy and bilateral oophorectomy that involve the removal of your uterus and both ovaries, will immediately stop menstruation.

What are the complications caused due to menopause?

Some of the possible complications associated with menopause include the following:

• Your risk for heart and blood vessel (cardiovascular) diseases increases with the decrease in oestrogen production.
• Your bone density may decrease, making them brittle and leading to a condition known as osteoporosis. This can make you more prone to fractures.
• Your vaginal and urethral tissues will begin to lose their elasticity, and you may experience the sudden urge to urinate, or may lose control over your bladder (urge incontinence or stress incontinence). You may also become more prone to urinary tract infections.
• The loss of moisture and elasticity of your vagina can cause discomfort during intercourse, and can affect your sexual desire (libido).
• As the rate of your metabolism slows down, you may start gaining weight.

How is it diagnosed?

Your doctor can identify your transition to menopause with your signs and symptoms. To confirm the diagnosis, your doctor may order blood tests to check your levels of follicle-stimulating hormone (FSH) and oestrogen (oestradiol), as a decrease in the level of these hormones can project menopause.

What are the treatment options?

Menopause itself needs no treatment, but treatment may be required to control its signs and symptoms. Your doctor will discuss the risks and benefits and may recommend any of the following depending on your condition.

Hormone replacement therapy: Your doctor may recommend treatment with hormones including oestrogen and/or progestin for your hot flashes and bone loss. It may also help prevent cardiovascular problems if started within five years of menopause.

Vagina oestrogen: Small doses of oestrogen in the form of cream, pills, or rings can help you manage vaginal dryness, urinary symptoms and discomfort during intercourse.

Antidepressants: Low-dose antidepressants can help you manage hot flashes when hormone replacement therapy is not advisable for you, and will also help improve your mood.

Medication treatment: You may also be prescribed medications to reduce your bone loss and risk for fractures.

Lifestyle Remedies

Some of these lifestyle remedies can also help you reduce or prevent the symptoms of menopause.

Cool off hot flashes by drinking cold water or staying in a cool room. Identify factors that trigger your hot flashes, like hot beverages, alcohol, caffeine and spicy foods, and try to avoid them.

Use water-based vaginal lubricants to help you with vaginal dryness and discomfort.

Reduce stress, get adequate sleep, eat healthy, stay active and don't smoke.

Exercise regularly. Certain exercises called Kegel exercises can help you strengthen your pelvic floor muscles and improve urinary incontinence.

Conclusion

Menopause is an unavoidable phase in every woman's life. Its signs and symptoms can be often disturbing, but it is important to understand your body and learn ways to cope with your difficulties. There are various options available to successfully manage your distress, and your doctor will be the right person to guide you through.

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