Abnormal Bleeding
Normal Periods
A woman normally loses between 30 and 40ml of blood with her period (6 to 8 teaspoonfuls) each month but there is much variability. Bleeding can last up to eight days, but bleeding for five days is average.
Heavy and Irregular Periods
Heavy menstrual bleeding also known as menorrhagia—is more than just an inconvenience. It can significantly impact your physical health, emotional well-being, and daily life. Heavy periods can result in a drop of iron levels and red blood cells. You may feel tired more easily, feel weak or dizzy or short of breath and may have chest pains. If you believe that your periods are either unusually heavy, prolonged or both, there are many different treatment options available to you.
How do I know if my periods are heavy?
You may or may not have some of the following problems:
-Losing more than 5– 6 tablespoons of blood (80mls
-Passing clots that are larger than a 50 cent coin
-Bleeding so much that you have to change your pad/tamponevery hou
-Having to get up most nights to change your pad/tampon
-Having to put a towel in your bed or use large maternity padswhen you sleep
-Bleeding through clothing
-Have bleeding that lasts more than eight days (prolongedbleeding)
What causes Heavy and abnormal Periods
Heavy menstrual bleeding can be as a result of three main causes:
• Hormone
• Changes within the uterus (womb)
• Blood disorders
Some causes of heavy menstrual bleeding can be identified through investigations.
What tests might be needed?
-Examination: Sometimes the bleeding is coming from the cervix, not the uterus itself. Your doctor can examine the cervix to see if this is the source of bleeding. This is done in a
similar way as a Pap smear or HPV screening test
-Blood tests may be ordered to look for anaemia, iron level, thyroid disease or bleeding disorder.
-An ultrasound of your uterus and ovaries (preferably done vaginally) can be used to detect abnormalities in the uterus such as polyps or fibroids.
-Internal swabs may be done to exclude any pelvic infection.
-A sample of the lining of the uterus may be taken (biopsy) to determine if there are any precancerous or cancerous changes.
-A hysteroscopy, which is a procedure used to examine the inside of the uterus using a narrow telescope, may be performed. Samples of the lining of the uterus will be taken at the same time. Polyps can also be removed at the time of Hysteroscopy.
Treatments
It dependent on cause of bleeding, desire for birth control, your fertility wishes in the future, other medical concerns you may have. Treatments can be either medical or surgical.
Medical treatments
This include both hormonal and non-hormonal options.
- Non-hormonal treatments- aim to decrease blood flow and reduce cramping and pain.
- Hormonal treatments- use hormones that mimic those in your body, either a combination of oestrogen and progesterone or progesterone alone. The most effective hormone method is the intrauterine device, which releases progesterone hormone into the local area of the lining of the uterus.
Surgical treatments
There are several options to control bleeding:
- Hysteroscopy- Polyps and small fibroids can be removed at hysteroscopy.
- Laparoscopy (Key-hole surgery) or open surgery. Larger fibroids which are too big or in the wrong position to be removed by hysteroscopy can be removed using these surgical techniques.
- Endometrial ablation- This treatment involves using energy to destroy the lining of the uterus. It is only suitable if you do not plan to become pregnant. Endometrial ablation can be done as a day procedure.
- Hysterectomy. This treatment involves an operation to remove the uterus via keyhole, vaginal or abdominal surgery. Hysterectomy is a permanent cure of heavy bleeding. It would be considered and is discussed when other treatment options have not been effective, are not suitable, or if this is the treatment you would prefer. At the Bay Gynecology, most hysterectomy are performed via key hole Surgery.
Ovarian or Adenexal Cysts/Mass
Do you have Ovarian Cyst?
What is Ovarian Cysts?
Ovarian cysts are sacs filled with fluid that form in an ovary or on its surface. Cysts can affect one or both ovaries. Ovarian cysts are very common. Most are harmless and go away without needing treatment. Sometimes ovarian cysts can be cancerous, but this is rare, especially before menopause.
You may not have any symptoms due to ovarian cyst. Sometime, ovarian cyst can cause your ovary to move or twist, which can be very painful. This can reduce or stop blood flow to your ovary and is an emergency situation. Ovarian cysts can also burst (rupture). This can lead to severe pain and bleeding in your pelvis.
Most ovarian cysts don’t need treating. They usually go away on their own. Some ovarian cysts may need to be removed. For example, if they are persistent after 3 months, keep growing, are larger than 5 cm, cause symptoms that impact your daily life, could become cancerous.
Ovarian cysts are usually removed via a laparoscopy (keyhole surgery) performed through small cuts in your abdomen). If deemed suitable, You may also be recommend to use the Pill to help prevent the growth of more functional cysts.
Abnormal Pap smear or Cervical Screening Test
What is cervical cancer?
Cervical cancer is an abnormal growth of cells in the cervix. If left untreated, it can grow and spread in the body, causing symptoms such as abnormal vaginal bleeding or discharge. There are two main types of cervical cancer. The most common type arises in the squamous cells of the cervix, accounting for about 80% of all cases. Adenocarcinoma arises from the glandular cells (cells that produce a secretion), and accounts for about 20% of cases. There are some other very rare types that are not easily detected by cervical screening. Nearly all cases of cervical cancer are caused by a persistent HPV infection.
Can cervical cancer be prevented?
Girls can be protected against the most common types of HPV (16 and 18) that cause cervical cancer by having HPV vaccination while at school. Women can be screened using the Cervical Screening Test for the presence of HPV infection in cervical cells. If detected, treatment for cervical cell abnormalities is simple and successful. A repeat test in one year to see if the infection is persistent may be required or further investigation by colposcopy.
Why do women who have been HPV vaccinated need the Cervical Screening Test?
The HPV vaccine does not protect against all of the HPV types that can cause cervical cancer, so it is very important that all women, vaccinated or not, continue to have a Cervical Screening Test every 5 years.
What happens if the test results are abnormal or your bleeding pattern is abnormal?
Your doctor will make a recommendation about the need for further tests or investigation: If HPV is detected, you will need earlier follow up, as recommended by the laboratory and your doctor. This may involve referral to a specialist for colposcopy or a repeat HPV test in 12 months.
Colposcopy and biopsy
This is the examination of the cervix using a colposcope, which gives a magnified view of the cervix. It allows the specialist to find any cell changes and to assess the extent of the changes. A colposcopy generally takes 10 to 15 minutes. You may feel some minor discomfort during the colposcopy.
A special instrument called a speculum (the same instrument used during a Cervical Screening Test) is inserted into your vagina. This will hold the walls of your vagina slightly apart so we can see the cervix. The colposcope does not go into your vagina, but is positioned between your legs to allow the doctor to examine the cervix.
After inserting the speculum, the specialist will dab the cervix with very dilute acetic acid (vinegar) solution. This will help to identify any abnormal cells. Most women do not find this painful although it may sting. With the colposcope it is possible for the specialist to see the area and pattern of abnormal cells. It is important to check if the abnormal area is only on the
outside or if it goes into the canal of the cervix. When abnormal areas are identified, the doctor may take one or two small biopsies (samples of tissue from the surface of the cervix). This can cause mild discomfort or menstrual-type cramp.
What to expect after Colposcopy?
After a colposcopy with a biopsy, you may experience cramping similar to menstrual pain. You may take simple pain medication to relieve the pain. There may also be some light bleeding or vaginal discharge for a few hours. Your doctor will advise you not to use tampons or have sexual intercourse for 3 to 4 days after a biopsy to enable the cervix to heal and reduce the risk of infection.
A follow up appointment will be made to discuss results if a cervical biopsy or repeat cervical screening test has been completed. At the appointment, the doctor will make recommendations as to your need for treatment or not.
Menopause/Perimenopause
Do you suffer from troublesome Menopausal symptoms?
Menopause is when you have your final period. Menopause is a normal part of ageing.
In Australia, the average age of menopause is 51. It’s normal to reach menopause between the ages of 45 and 55 years. Some women reach menopause earlier ( premature or early menopause) or later than this.
What causes Menopause?
Menopause is caused by a drop in certain hormones such as oestrogen. From about 35 to 40 years of age, you have fewer eggs left in your ovaries and don’t release an egg from your ovary as often. Menopause means your ovulation and periods stop. Menopause can sometime be caused by some medicines, cancer treatment or operations like hysterectomy or ovary removal.
What is Perimenopause?
It's the time leading up to menopause. During this time, your ovaries begin to run out of eggs. This causes hormone levels, particularly oestrogen, to change, causing different symptoms like hot flushes and mood changes. Even though fertility is lower in your 40s and 50s, it is possible to become pregnant. This is because you still ovulate during perimenopause.
The chance of pregnancy in women aged 45 to 49 years is about 2% to 3% per year. After the age of 50, it’s less than 1%. But it’s important to remember that every woman’s fertility is different.
Hormone Replacement Therapy is not a contraceptive.
What can Menopause bring?
Lower levels of oestrogen after menopause can affect your bladder and Vaginal health causing incontinence, Vaginal dryness, Painful sex.
Before menopause, women have a lower risk of heart disease than men. But, as women age and their oestrogen levels fall, their risk of heart disease increases. Heart disease is one of the leading causes of death for women in Australia.
After menopause, lower levels of oestrogen affect women’s bone health, which puts them at greater risk of developing osteoporosis.
After menopause, you may notice extra body fat around your belly. This can increase your risk of health conditions such as type 2 diabetes, heart disease, dementia and some cancers.
You can reduce the risk of heart disease and Osteoporosis by having a healthy lifestyle, regular exercises.
Prolapse & Urinary Incontinence
Do you suffer from Prolapse or Urinary Incontinence?
Prolapse presents with symptoms of heaviness and pressure in the vagina and pelvis.
Patients sometimes describe it as a feeling of ‘bulge’, something coming down from or out of the vagina. Sometimes women say it feels as if they’re sitting on a ball or an orange.
Typically, these symptoms become more pronounced as the day goes on and towards the end of the day when patients report being more aware of the bulge or being more bothered by it.
Urinary incontinenece
An estimated 37% of women in Australia are living with some degree of urinary incontinence. There are various type of Urinary incontinence.
Risk Factors- include pregnancy and childbirth, obesity, menopause, certain types of surgery and some neurological and musculoskeletal conditions. Vaginal delivery, especially with instrumental delivery, is a significant risk factor for incontinence and Prolapse.
Management- Conservative approaches should be the first choice of treatment for Prolapse and Urinary incontinence.
The aim is to encourage the patient to modify risk factors and lifestyle including weight loss, the promotion of good bladder and bowel habits, proper fluid management (decreasing caffeine and alcohol intake), quitting smoking and avoiding excessive fluid intake.
Pelvic floor rehabilitation is critical.
Pessaries can also be used as part of this conservative approach for these two conditions. They are inserted in clinic during a physical examination.
Surgery would be considered based on a number of clinical factors and the woman’s own wishes. Women who have advanced prolapse might not be suitable for a conservative management and would benefit more with surgery.
Pelvic Pain
What is Period Pain?
Period pain also called as Dysmenorrhoea is when your uterus muscles tighten at the start of your period. This pain can contribute to persistent pelvic pain. Pain that interferes with your life is not acceptable. Please seek medical advice about treatments for period pain as this could be endometriosis or an alternative cause that should be investigated.
There are several conditions which can cause persistent pelvic pain as discussed below.
Endometriosis
Endometriosis is a condition where cells similar to those that line your uterus are found in other parts of your body, mainly in the pelvis. It is a chronic, inflammatory, gynaecologic disease.
The causes of endometriosis are not fully understood.The symptoms associated with endometriosis vary. Some people might experience very little or no pain, while others have significant pain that substantially affects their quality of life.
Endometriosis has been associated with debilitating painful symptoms, a long delay in diagnosis, and ongoing symptoms despite medical and surgical treatments. A direct family history of endometriosis or any history of autoimmune disease might increase your chance of having endometriosis.
Adenomyosis
Adenomyosis is when cells like the lining on the inside of your uterus are also in the muscle wall of your uterus. Studies suggest that about one in five women have this condition. With adenomyosis, the cells in the muscle wall behave the same way as cells lining the uterus. When you have your period, the cells in the muscle wall also bleed. But because they are trapped in the muscle layer, they form little pockets of blood in the muscle wall. This can cause painful and heavy periods.
Pelvic Floor dysfunction
Your pelvic floor muscles are part of a group of muscles called your ‘core’. Tight pelvic floor muscles can cause painful sex and pelvic pain, which can contribute to persistent pelvic pain.
Vulvodynia
Refers to chronic pain or discomfort in the vulva that lasts for at least 3 months. With this condition, any pressure applied to the vulva, such as having sex, inserting a tampon or sitting for long periods of time can be unbearable.
Irritable Bowel Syndrome
It's a group of symptoms, such as bloating, constipation, diarrhoea and pain in your abdomen, which can contribute to persistent pelvic pain.
Painful Bladder Syndrome and Urinary Tract Infections
Painful Bladder Syndrome is a condition where you have bladder pain and a frequent and urgent need to wee. Symptoms include pressure, pain and tenderness in the pelvis, which can contribute to persistent pelvic pain. Urinary Tract infection can sometimes cause pelvic pain.
Psychological factors
Psychological factors can also contribute to persistent pelvic pain or make it worse.
Poor sleep can increase the likelihood of pain and pain sensitivity. Pain on the otherhand can affect the quality and duration of your sleep. Disturbed sleep is also linked to depression and anxiety, which are more common with persistent pelvic pain.
Stress activates your nervous, hormone and immune systems, which causes changes in your body and brain. These changes can affect you physically and psychologically, which can contribute to persistent pelvic pain.
Past Traumatic experiences such as sexual assault and abuse, can contribute to persistent pelvic pain