Gynaecology

Although each woman is different, they don’t often discuss or compare what their ‘normal’ experiences are. A ‘normal’ cycle can vary from between 21 and 40 days, with the duration of bleeding between two and seven days. What isn’t normal, is when the amount of bleeding exceeds 100ml a month, which is roughly half a cup. Many women put up with losing more than this normal amount, with large clots and pain which can lead to reduced iron levels and potentially Anaemia, over a long period of time. Anaemia presents as tiredness, recurrent illnesses, shortness of breath and a general feeling of just being old and miserable.

Heavy periods may be caused by:

• Polyps or Fibroids. These are soft benign growths in the uterus.
• Adneomyosis. Where the uterus is globular and bulky because the lining grows through the uterus wall. This is painful before and during periods.
• Hyperplasia. This is when the lining thickens, which can be benign, precancerous or a sign of Endometrial cancer.
• Non-physical. Meaning there is a hormonal imbalance potentially caused by an egg being developed but not released. Coagulation disorders like Von Willibrand deficiency could also contribute.

Investigate into the cause behind non-normal heavy periods can include an ultrasound to look for physical changes, a Dilation and Curettage operation to test the lining or a Pipelle endometrial biopsy which can be done in the consulting rooms.

Treatment options:

Treating heavy periods will vary between patients.

• It could be a non-hormonal treatment, or
• A hormonal treatment like a contraception pill or long acting IUD (Mirena), or
• Surgeries like Novasure Endometrial Ablation, or a Hysterectomy where necessary (rendering future pregnancies impossible).

Like any surgical procedure, removing the uterus/womb is a balance of risk versus benefit. Ultimately it is a choice for each person to make, however there can be several options available before this final, irreversible surgery. You may choose to explore these options or opt for the surgery from the beginning – it is your choice.

Performing a total Hysterectomy involves removing the uterus, the tubes and the cervix, but leaving the ovaries in place. Recent studies have shown that 70% of what was believed to be Ovarian Cancer was in fact Tubal Cancer, so removing the tubes is now considered good practice.

A subtotal Hysterectomy (abdominal only) involves also leaving the cervix in place. It is thought that by removing the cervix it will affect sexual function (which I personally don’t believe) but leaving it is thought to help reduce the risk of prolapse.

If the Ovaries are also removed during the procedure, a surgical menopause is triggered, which can sometimes be more difficult to endure than natural menopause. Generally, it is not recommended.

The technique chosen to remove the uterus will be dictated by the size, the pathology and the surgeon. Personally, I prefer the vaginal or abdominal techniques, however the final choice will depend on the individual person, their needs and the safest route.

The aim of contraception is to be easily reversible, and not cause any side effects.

Contraception options include:

• Barrier Contraception. This includes condoms (latex or non-latex) worn during sex, where there is no genital contact without the condom and withdrawal occurs as soon as ejaculation has happened.
  This also includes diaphragm’s inserted in to the vagina before sex commences and removed six hours later. Oestrogen or progesterone pill combinations can be effective, each with different side effects.
  Long acting implanted devices are also an option such as Implanon which lasts for three years or Mirena (inserted under local anaesthetic). There is also a three-monthly injection which may take up to two years to reverse after stopping.
• Non Hormonal. There is an IUCD copper device that deters sperm moving up the tubes. Side effects of this method are heavy periods and occasional spotting.
• Tube Ligation. Clips are placed on the tubes, or the tubes are removed through key hole surgery. There is a small failure rate, generally caused by the tubes not being completely blocked, and there is risk of an Ectopic pregnancy. Removing the tubes is irreversible.

Prolapse can occur at any age but is more common in post-menopausal or post-partum women. It is often described like feeling a balloon between your legs, or inside the vagina, but is usually found by feeling a lump or something unusual down there.

In post-menopausal women, the lack of Oestrogen means the vaginal wall is losing elasticity, becoming like baggy lycra. In post-partum women, the first 6 months after giving birth are when you are most at risk of developing a prolapse.

Other causes can include weighted squats, pump classes or chronic coughing. Sometimes acute onset can be triggered by a viral coughing fit, or lifting heavy things in the garden.

Symptoms:

• Feeling a lump
• Frequently urinating, or feeling of not emptying
• Stress
• Incontinence, or leakage when coughing, sneezing or walking
• Having to push to defecate, or not emptying the bowel properly
• Pressure or discomfort during sex
• Prolapse will rarely present with bleeding, or recurrent UTI’s

Treatments:

• Non surgical. Exercising with a special pelvic floor Physiotherapist, or fitting a Pessary. Both GP’s and certain Physio’s can do this – it’s like a dress hoop being inserted to hold the prolapse up, which needs to be removed and cleaned frequently.
• Surgical. This could include a procedure to repair the vaginal wall, similar to creating a dart in sewing. Sometimes the cervix may need to be removed to lengthen the vagina and prevent further recurrence. Occasionally, a Hysterectomy may be performed if you present with heavy periods.

At your visit, we would discuss each option and go through the risks and benefits of each, relevant to your situation.

Recently, the use of mesh in vaginal repairs has been in the news. Personally, I don’t use any mesh because I believe the risks far outweigh any potential benefits.

Visit Eliza Barry at Kardinia Health for treatment options:

Other Physio’s who specialise in Pelvic Floor and Prolapses: