UTERINE FIBROIDS
Also called myomas are benign (non-cancerous) growths of smooth muscle tissue on or within the uterus. They are the most common type of growths found in a woman's pelvis. They occur in about 25-50% of all women. Many women who have fibroids are not aware of them because the growths can remain small and not cause symptoms or problems. However in some women fibroids can cause problems because of their size, number and location.
Causes
Fibroids are most common in women aged 30-40 years, but cans occur at any age. They tend to occur more often in African American women. In spite of fibroids being quite common, little is known about what causes them.
Symptoms
Most fibroids, even large one produce no symptoms at all. When symptoms do occur they often include: heavy bleeding, longer or more frequent menses, vagina bleeding at times other than menstruation and anemia due to the excessive bleeding. Pain may occur in the abdomen, lower back and with intercourse. Pressure is also associated with fibroids, along with frequent urination, constipation, rectal pain and abdominal cramps. The uterus may be quite large and thereby cause the abdomen to be large. Miscarriages and infertility are also associated with fibroids.
Diagnosis
The first signs of fibroids may be detected during a routine pelvic examination. There are a number of tests that may show more information about fibroids: Ultrasound, which uses sound waves to create a picture of the uterus or of the pelvic organs. Hysteroscopy uses a device similar to a telescope to help the physician see the inside of the uterus. It is inserted through the vagina and cervix. This permits the physician to see some of the fibroids inside the uterine cavity. .
Treatment
Fibroids that do not cause symptoms, are small or occur in a woman nearing menopause often do not require treatment. Certain signs and symptoms may signal the need for treatment:
Medication such as gonadotropin-releasing hormone (GnRH) agonist, may be used to shrink fibroids temporarily and to control bleeding to prepare for surgery. The choice of treatment depends on factors such as the patient wishes and the physician's advice and recommendations about the size and location of the fibroids.
Surgical removal is called myomectomy which leaves the uterus in place. Myomectomy may be rendered via out-patient such as laparoscopy, hysteroscopy and mini-laparotomy. The laparotomy myomectomy is usually an in-patient procedure. Hysterectomy is the removal of the uterus. The ovaries may or may not be removed.
ENDOMETRIOSIS
The lining of the uterus, is called the endometrium. If this tissue that normally lines the inside of the uterus cavity grows elsewhere in the body, it is called endometriosis. It is common in women in their 20 and 30s as well as women in their 40s, but can occur any time in women who menstruate. I have treated hundreds of patients in their teens who were not able to go to school during their menses due to severe debilitating cramps. Endometirosis occurs more often in women who have never had children. Women with a mother, sister, or daughter who have had endometriosis also are more likely to have it. Women who grew up or live near refineries or paper mills. Dioxin is an environmental hormonal toxin and byproduct of refineries and paper mills and is thought to be a factor.
Location
With endometriosis, tissue like the endometrium is found in other areas in the body. It looks and acts like tissue in the uterus. It appears most often in the ovaries, Fallopian tubes,surface of the uterus, cul-de-sac (space behind and under the uterus) bowel, bladder and ureters and rectum. It may also be found in other parts of the body, like the lungs, which is very rare. Endometrial tissue that grows in the ovaries may cause a cyst (endometrioma) to form. Further endometriosis is noted to be found in about 75% of women who have pelvic pain.
Symptoms
The symptoms of endometriosis varies. Pelvic pain, however is the most common complaint. In patients with pain it may occur before during or after the menses; in the lower abdomen, lower back, one or both legs, neck or shoulder, with defecation and with intercourse. Irregular or heavy menstrual bleeding, nausea or vomiting before during or after the periods. Frequent stools or diarrhea may also occur before during or after the periods. Some months the symptoms may be worse than others and tends to increase as the years go on. Infertility is another problem associated with endometriosis and can cause 30-40% of women with this disorder to be infertile. In addition it has been associated with early miscarriage in women who do get pregnant.
Diagnosis
The diagnosis of endometriosis can be made via a through history and pelvic examination(clinical diagnosis), however the gold standard is via laparoscopy. Endometriosis can be mild, moderate or severe, the extent of the disease can be confirmed and staged with laproscopy.
Treatment
The treatment of endometriosis depends on the extent of the disease, the patient's symptoms and the desire for children. It may be treated with medication, surgery or both. Although treatments may relieve pain and infertility for a time, symptoms may come back post treatment.
Medication
In some cases of endometriosis, medication or NSAIDs (nonsteroidal antiinflammatory drugs) may be used to relieve pain. Hormonal medication may be used to relieve pain by slowing the growth of the endometrial tissue. Some of them are gonadotropin-releasing hormone (GnRH), GnRH antagonists (elagolix and relagolix) progestins, letrozole and danazol.
Surgery
Surgery may be done to remove endometriosis and the scarred tissue around it. In most severe cases of the disease, surgery often is the best choice for treatment. Surgery most often is via laparoscopy, during which endometriosis can be excised or ablated.
PELVIC PAIN
Pain in the pelvic region is always of concern however one should be evaluated if it disrupts your daily life- either for just a few days each month or for longer. It worsens over time or you have noticed a recent increase in pain.
Causes
- There are many possible reason for pelvic pain. Finding its cause is a process that can take a long time. Often there is more than one reason for the pain and its exact source can be difficult to pin down. The following are some of the common causes:
Infection, of the tubes such as pelvic inflammatory disease (PID), caused by STDs, bladder infection and appendicitis
Ovarian Cysts a cyst is a fluid-filled sac. Some cysts of the ovaries form as a result of ovulation and bleed slightly causing pain. this usually occurs around the middle of the menstrual cycle and goes away in a day or two. Other cysts may occurs that does not dissappear may cause pain by twisting or it's large size. Some of these may need to be surgically removed. In rare cases some ovarian cysts may even be cancerous.
- Endometriosis or adenomyosis, endometriosis is discribed above, however adenomyosis is when the endometrium (lining of the uterus) is displaced into the muscle of the uterine wall. this can cause menstrual cramps, pressure, bloating like feeling in the lower abdomen before periods and heavier bleeding during periods.
- Adhesions from previous major abdominal surgery, endometriosis, PID, and infections may cause pelvic pain.
Diagnosis
Because there are so many possible causes of pelvic pain, finding its cause is a process of elimination. A complete history and pelvic examination is mandatory along with various blood tests, ultrasound and other studies.
Laparoscopy is an excellent tool to evaluate the pelvis and therefore the cause of pain, particularily as mentioned endometriosis, pelvic adhesions, PID, ovarian cysts and many other problems.
Treatment
Many of the problems may be treated via laparoscopy. In addition heat treatment, muscle relaxants, nerve block and relaxation exercises may all help to treat other causes of pelvic pain. if disorder of the bladder, bowel or other organs are the cause of the pain, specific treatments for those condition should be used.
INFERTILITY
Infertility is the inability of a couple to get pregnant after frequent coitus for a year or more. Obviously the couple who desires a child and has difficulty is burden with stress as to how family and friends, view their problem and they themselves view and handle the problem. The female is generally thought to be the problem, however it should be noted that 35% of the time the cause is the male and 35% it is the female, 25% both are responsible or have a problem and 5% the cause is unknown.
Causes
The cause of infertility can best be expressed with factors.
Factors Male
The male may have a low sperm count or none in rare cases. In addition infections, smoking, excessive alcohol and/or drugs may have an effect. Generally a semen analysis will help to discern whether the cause of infertility is related to the male factor.
Cervical
The cervix is the tip of the uterus, fortunately it can be evaluated with a regular pelvic examination. Problems with the cervix are infection and inflammation, lacerations or stenosis (the opening is to small).
Endometrial
The endometrium is the lining of the uterus. If there is heavy bleeding and clots this may indicate there is a problem with the lining such as fibroids, polyps, infection, and or scar tissue from previous surgery such as a D & C. An ultrasound, or hysteroscopy may be helpful to ascertain whether there is a problem with this factor.
Tubal
The fallopian tubes are connected to the uterus and ovaries they serve as a connector to the uterus for entrance of the sperms into the tubes and to pick up the eggs from the ovaries wherein the eggs joins with the sperms in the tubes. There after goes back into the uterus and the embryo is formed and growth of the baby proceeds. If the tubes are blocked and swollen due to infection, or if adhesions secondary to previous surgery or endometriosis is present the process for the eggs to be picked up may not occur and therefore infertility is the resultant. The tubes can be evaluated via HSG and laparoscopy.
Ovarian
The ovaries, release the eggs during ovulation. If this process does not occur or is impeded due to failure to ovulate, secondary to medications such as oral contraceptives, endocrine problems such as diabetes or polycystic ovaries (numerous cysts in the ovaries and thick covering). Physical problems such as infection tuboovarian abscess, endometriosis causing adhesions and cysts or surgery causing similar problems. Laparoscopy may be necessary to evaluate the extent and for treatment of the physical problems and medication may be used for others.
Peritoneal
The peritoneum is the lining of the pelvis and is similar in appearance to the lining of the mouth. If adhesions, scar tissue from infection, previous surgery or endometriosis or combination thereof is present this may affect pregnancy.
Endocrine
Endocrine problems such as thyroid disease, diabetes and a number of others can have an impact relevant to getting pregnant. Therefore tests to evaluate this system is necessary and if positive treatment should be rendered.
Endometriosis
Endometriosis is a common problem that can cause 30-40% of women with this disorder to be infertile. It can cause severe cramps, adhesions and scarring along with ovarian cysts filled with the disease. A complete history, pelvic examination and laparoscopy is necessary to discern the extent of the disease and to treat it. Excision at laparoscopy and medication post the procedure is necessary in some cases.
MENORRHAGIA (heavy periods)
Menorrhagia is defined as heavy vaginal bleeding or blood loss of four soaked maxi pads or five soaked tampons per cycle or greater. It affects 20% of reproductive age women worldwide and has a significant impact on their lifestyle. It can cause embarrassment, loss of work days, anger, depression, lost family time, fear, impact on sexuality, sense of loss and impact on health.
Causes
Hormonal imbalance may be caused by hormonal changes in women nearing menopause, obesity, diabetes, thyroid disease, stress, anorexia and other eating disorders. Uterine growths these growths usually fibroids or polyps are almost always non-cancerous. In addition adenomyosis a condition similar to endometriosis wherein the uterine lining is displaced to the muscle wall of the uterus and can cause bloating, pain and heavy bleeding. Other bleeding disorders or problems with blood clotting, infections of the uterus and medications are additional problems that may cause menorrhagia. Cancer or pre-cancer of the uterus, cervix or vagina may also cause menorrhagia.
Diagnosis
The diagnosis is made via a complete history and pelvic examination along with an estimation of the amount of blood loss and a blood test to discern whether anemia is present. Other tests based on the patient's symptoms are endometrial biopsy wherein a small amount of tissue is scraped from the lining of the uterus in the office and evaluated. Ultrasound is used via sound waves to create a picture of the pelvic organs. the device may be placed on the abdomen or in the vagina. Hysteroscopy is the utilization of a device similar to a telescope (hysteroscope) to see the inside of the uterus. Dilation and curettage (D&C) with this procedure the cervix is opened wider and tissue is scraped form the lining of the uterus to be examined under a microscope.
Treatment
The treatment is dependent on the finding from the examination and various test along with the desires of the patient. Surgery or one of the new medications such as GnRH antagonist can generally abate the bleeding while the patient is on the medication. This can be used for a number of months without major problems.
