This is an extremely common and painful condition which can cause pelvic pain and heavy bleeding. It can only be accurately diagnosed by means of laparoscopy. This enables both diagnosis and treatment through a keyhole procedure. Endometriosis could also significantly affect a woman’s ability to get pregnant.
When treating endometriosis through a laparoscopic/keyhole procedure, it is also important to start some form of preventive therapy (as the risk of recurrence is significant), unless of course the woman is trying to get pregnant.
Infertility investigation & treatments (before IVF)
The three important factors to assess in couples wishing to conceive are Sperm Function Tests, Ovulation (egg release) and the state of the fallopian tubes and pelvis.
The best assessment of the pelvis is achieved by means of a laparoscopy (a keyhole procedure involving an incision through the umbilicus/bellybutton) which allows a direct inspection of the pelvis. In addition to checking for “blocked Tubes” this procedure could also reveal disease which might be asymptomatic (silent) such as endometriosis and adhesions which are not detected by the standard tests (HSG and Hycosy which are done using x-ray or ultrasound techniques).
Failure to ovulate (release eggs) are often associated with polycystic ovary syndrome PCOS and may require treatment with metformin and Clomid.
Pelvic pain, painful sex
These common symptoms frequently due to pelvic disease such as endometriosis, adhesions from previous infection or inflammation, ovarian cysts et cetera. Ultrasound and laparoscopy are recommended in these situations.
Prolapse & bladder problems
Women who’ve had normal deliveries are prone to these symptoms, particularly worsening as they get older and reach or pass the menopause as the tissues become weaker.
Pelvic floor exercises taught by specialist physiotherapists can be very helpful but often surgery is required.
If urinary leakage on coughing and laughing exercise etc is a problem this can be helped by a TVT (suburethral tape) procedure which is done as a day case. If there is an actual bulge present an additional “repair” procedure may be necessary.
This is a particularly troublesome and unpleasant form of prolapse which involves a weakening of the back wall of the vagina which is in very close proximity to the rectum.
Patients often complain of an inability to empty the rectum completely and often have to support the back wall of the vagina to evacuate completely. They also complained typically of a feeling of fullness in the rectum which they cannot get rid of, which bulges into the vagina itself.
This can be rectified a combination of physiotherapy and a posterior repair.
Sexual problems, loss of libido
This can be due to a number of factors and a careful analysis is important. Sometimes there are no physical causes such as painful scarring from childbirth, infection or menopausal dryness.
Loss of libido (sex drive) can be a very distressing condition for woman and can have a severe impact on her relationship leading to breakdown of relationships. It frequently responds to testosterone treatment particularly in the form of testosterone implants.
This is a huge area and gynaecology and can affect women at any time of the lives. It can give rise to symptoms such as abnormal menstruation, excess hair growth greasy skin et cetera as an polycystic ovary syndrome. Sometimes menopause or premature menopause can occur. Premenstrual syndrome is about the common situation in which hormonal fluctuations can give rise to profound mood changes during the menstrual cycle.
It is important to carry out an individual assessment of each woman to find out which had the most prominent symptoms in order to reach a diagnosis and start effective treatment. (See individual symptoms.)
HRT and the Menopause
This is a very controversial subject and the popular view in the media seems to change regularly from one extreme to another. Unhelpful and a badly constructed research studies have made this worse.
HRT can be a powerful and life enhancing boost for women at a critical time in their lives. Many are reaching the peak of their careers, at the same time as having increasing concerns for elderly parents and still-dependent offspring! Superimposed on this, menopausal symptoms such as disturbed sleep, tiredness, lack of concentration etc can wreak havoc on a woman’s quality of life.
An individual assessment including the risk assessment is extremely important. In addition tailoring the therapy to the individual woman is vital in getting the right result.
This is a huge area in gynaecology and in fact accounts for the largest number of consultations with general practitioners.
No woman should have to put up with unacceptable bleeding whether it be heavy bleeding, prolonged bleeding, unpredictable bleeding, too frequent periods or bleeding between periods or premenstrual spotting.
Finding the right treatment for that woman would involve a number of factors most importantly whether she has completed her family or intends to have a family. A detailed and careful assessment is required.
Treatments can range from the simplest least invasive approach to the final definitive solution, the hysterectomy depending on her individual requirements and most importantly her feelings on the subject.
Polycystic ovarian syndrome (PCOS)
This is an increasingly important subject as it is now being recognised more readily. This is compounded by the fact that increasing BMI (weight) in the population is an important contributory factor to the increasing incidence of PCOS.
Although it is called Polycystic Ovarian Syndrome the problem does not ARISE ie begin in the ovary. PCOS is a metabolic disorder involving Insulin and Glucose. After a meal the food contents particularly sugar and starchy foods (ie carbohydrates) are broken down into glucose. Blood glucose therefore rises and this prompts the release of Insulin from the pancreas gland. Insulin causes the passage of the glucose into the body’s cells and blood glucose levels fall.
HOWEVER PCOS patients have the phenomenon called Insulin Resistance ie the Insulin is less effective and therefore more of it is pumped out by the pancreas gland to bring down the blood glucose. It is this HIGH LEVEL OF INSULIN which causes the ovary to “malfunction”. This often leads to failure to release eggs (ovulation) and hence difficulty in conceiving as well as menstrual irregularity (sometimes very scant or absent periods).
A higher level of androgens(male hormone) is produced by the ovary which can cause greasy skin acne and increased hair growth. If thes PCOS women get pregnant there is the risk of Diabetes in pregnancy. There is an associated increase risk of Diabetes in later life.
Metformin is widely used to correct Insulin Resistance and assists weight loss.
Premenstrual syndrome (PMS)
This is extremely common and can affect a woman at any time in her reproductive life. It does not occur after the menopause or before puberty because there were no hormonal fluctuations taking place.
In the most extreme form it can lead to disruption of interpersonal relationships and can cause problems within the family and at work with serious consequences.
It can be easily treated effectively and safely by hormonal manipulations the most successful of which is the combination of the Mirena and oestrogen patches which has been safely evaluated and found to be effective.
This is an extremely common symptom which is usually very benign but nonetheless extremely wearing for large number of women. It is very often due to benign conditions such as an ectropion (often referred to as an “erosion”) or cervical polyps. It can be easily treated (cauterised) under local anaesthetic quickly and easily in an outpatient setting. It is also relatively painless treatment. For reassurance, is always recommended that a cervical smear is done prior to the treatment.
An ectropion is nothing sinister. It is simply a cluster of delicate blood vessels/capillaries on the cervix which can bleed on contact such as during intercourse, taking a smear or simply on exercise.
See below for detailed description of cervical ectropion.
Cervical erosion (ectropion)
The normal cervix is covered by an epithelium i.e. a “skin” similar to the rest of the body and is known squamous epithelium. However, the canal inside the cervix which leads up to the uterine cavity is lined by a different type of tissue/epithelium known as columnar epithelium which contains lots of blood vessels and mucous glands. Therefore an ectropion is caused by the extension of this
columnar epithelium out onto the outer surface of the cervix. Therefore it is no surprise that it can cause an excessive mucus discharge which is not infective but some women to find an acceptable. As already mentioned above and ectropion can also cause bleeding during sex, exercise etc.
In the United Kingdom cervical smears are only done from the age of 25 onwards, every 3 years until 50. From 50-65 it is done every 5 years after which routine smears cease.
This can be a source of much anxiety to patients who may have worrying symptoms such as bleeding between periods, after sex et cetera and can’t get a smear test.
Some patients have had bad (and painful) experiences with attempts at cervical smear- taking and are put off by this. In the hands of skilled and experienced practitioners, it is almost always possible to get a good quality smear test to assess our patients.
Coils, Mirena & Contraception
The Mirena is one of the greatest developments in recent decades in gynaecology. Like any form of treatment but is not ideal for every woman but for the large majority it isn’t excellent form of menstrual control, as well as providing a reliable and reversible contraception. It can be used at any time in the woman’s life and in experienced practitioners can be inserted easily even in women who’ve not had deliveries, and in younger women who have never been pregnant.
It helps to lighten periods, relieved premenstrual syndrome and help bring about an easy transition into the peri-menopause and post menopause stage of a woman’s life. It can easily be supplemented with a small dose of oestrogen to help PMS and menopause symptoms if required.
For women who prefer the copper device or the Pill, a full and informed discussion can be helpful in making the right choices. Again it is important to individualize the care for a given woman.
This is an area which is not well provided for or prioritised in the NHS. The condition causing concern may be painful (eg been stitched up too tightly) or scar tissue from delivery etc. In other situations it may be that the labia minora (the inner lips) are too long and get caught on underwear or during sex.
It might be embarrassing e.g. protruding out of a swimming costume or just very uncomfortable on wearing jeans or trousers. These can be rectified by quick and straightforward procedures often possible under local anaesthetic.
Some women have moles or other lumps which become painful and uncomfortable or rub against clothing, which can be easily removed.
These are widely used for HRT and boosting libido and are very convenient for many women. They are no longer available on the NHS and have to be imported on an individual patient basis.
They are usually inserted 6-12 monthly. A blood test is required before a repeat implant to check against excessive levels developing which can then lead to decreasing effectiveness. Please call for more details.
Cervical cancer is now widely regarded to be caused by HPV human papilloma virus. Young girls at school are being vaccinated in the early teens. However, many women have missed out on this opportunity but can still benefit from the vaccine which involves 3 injections over a six-month period. These can be arranged when required.
Ovarian cancer screening
Ovarian cancer is a common condition for which there is no widespread screening program available. However, the combination of a detailed ultrasound scan together with blood tests looking for tumour markers can be very valuable. For those women with a family history, genetic counselling can be arranged.
2 commonest occurrences are weakness of the bladder neck at the junction between the urethra and the bladder itself which can lead to stress incontinence ie leakage of urine on coughing sneezing and laughing movement, sport et cetera.
This can be cured by a suburethral tape sometimes done as a TVT or TOT. This is done as a day procedure and recovery time is usually one week.
Other common problem which affects the bladder is that of a prolapse with the bladder itself has physically dropped or sometimes it could be the bladder plus the cervix and sometimes the back wall of the vagina (see rectocele). These require an operation to correct the bulge/lump and requires a general anaesthetic and one or 2 nights in the hospital. Recovery is in the region of 4-6 weeks in terms of return to work and driving etc.
This is a very common gynaecological investigation and treatment and is done through a keyhole incision made through the belly button (umbilicus) recovery is usually one week.
Is a camera inspection of the inside of the womb and can be done under local anaesthetic. However it sometimes required a general anaesthetic if a more complex procedures required such as removing a large fibroid or polyp.
This is the removal of the uterus and sometimes might include the removal of the ovaries and the cervix depending on the indication for the operation. It can be done through a bikini line incision or through the vagina depending on the circumstances.
Except where malignancy is suspected this can almost always be removed through a laparoscopic keyhole procedure with the patient discharged home the same day.
See above section under bladder repair.
This is an extremely effective treatment for heavy periods in a woman who has completed her family. It can be done under local anaesthetic or general according to the woman’s preference. The new techniques such as a radiofrequency ablation requires no more than 2 min of “lasering time”. Typically the whole procedure can be completed in 15-20 min.