Diagnosis

WHAT IS ABNORMAL UTERINE BLEEDING?

• Bleeding between periods
• Bleeding with intercourse
• Bleeding longer than usual
• Bleeding more heavily than usual
• Spotting during your cycle
• Bleeding after menopause

There are many reasons you can deal with abnormal uterine bleeding at some point in your life. Some of these reasons are minor and may even resolve on their own, while others can be more serious and require medical attention and possibly a hysterectomy.

Any time that you experience hormonal imbalance, you can have abnormal bleeding. Stress, a new exercise plan, or even big changes to your diet can also affect your cycle. While abnormal uterine bleeding can occur at any age, it may worsen during perimenopause.

There are also specific health issues that can cause abnormal uterine bleeding:

• Pregnancy or miscarriage
• Adenomyosis
• Endometriosis
• Fibroids
• Polyps
• Polycystic ovarian syndrome (PCOS)
• Gynecologic infection
• Gynecologic cancer
• Bleeding disorder
• Hypothyroidism
• Liver disease
• Chronic renal disease

In addition, hormonal treatments (IUD, birth control pills), blood thinners, irritation of the genital area, trauma, or a reaction to foreign bodies could lead to abnormal uterine bleeding.

TREATMENTS

Abnormal uterine bleeding can be treated in a number of ways depending on the cause, your age, fertility concerns, and your overall health. In some cases, a “wait and see” approach may be all that is needed. In other cases, you may need hormonal treatments, an endometrial ablation, a D&C, or a hysterectomy.

If you experience abnormal uterine bleeding of any kind, you need to talk to your doctor. Besides sharing your symptoms, you may need a physical exam, blood work, testing, and a family history evaluation to help your doctor determine the cause of your bleeding. While abnormal bleeding can occur for a variety of reasons throughout your life, it is never normal during menopause and should not be ignored.

Adenomyosis is a condition where the endometrium (lining of the uterus) grows into the myometrium or muscular wall of the uterus. As a result, the uterus can become enlarged and even boggy, leading to discomfort, pain, and other symptoms. Most frequently, women will experience intense menstrual cramps, heavy and prolonged menstrual bleeding, and abdominal bloating. Other symptoms may include lower back pain, abdominal pressure, and painful intercourse. Additionally, women can pass blood clots during their period, have breakthrough bleeding, and feel fatigued. Due to excessive bleeding, some women also experience anemia.

Though the cause of adenomyosis is unknown, there are some risk factors that may cause or contribute to the condition. These include hormonal issues, prior uterine surgeries including a myomectomy or C-section, childbirth, or other trauma to the uterus that could cause displaced endometrium. Typically, women diagnosed with adenomyosis will be in their 40s and 50s, but younger women may be diagnosed as well.

Adenomyosis is completely contained within the uterus, and it is not internal endometriosis as was once believed. Both conditions involve endometrial glands and stroma in abnormal areas, but the two conditions act and respond differently.

There are a wide variety of treatment options available depending on your symptoms and how close you are to menopause. These can include both pharmaceutical and surgical options.

Keeping a symptom diary can help you and your medical team determine which choice(s) might be right for you as your symptoms can play a role in which options may be best. In addition, your fertility concerns will need to be taken into consideration as some choices prevent future pregnancies. If you wish to retain your fertility, you may want to work with a fertility specialist to ensure that fertility is maintained if at all possible.

Which ever option you choose, or if you choose to “wait and see,” staying in touch with your doctor can help both of you monitor your prognosis. Adenomyosis is not considered a life-threatening condition, but symptoms can negatively affect your quality of life. In addition, you may have other co-existing health conditions which need to be treated.

TREATMENT OPTIONS

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs can be used to manage pain. These can include over-the-counter or prescription medications such as Ibuprofen, Naproxen, and Aspirin. If these are started a couple days before your period begins, they can relieve the pain during your cycle and decrease your menstrual flow. This option may help you manage your symptoms until menopause, which is when adenomyosis typically ceases to be an issue for some women.

Oral Contraceptives: These medications can control your menstrual cycle and hormone levels by providing a specific dose of hormones. They can also be taken continuously to prevent menstrual periods, thus alleviating symptoms related to bleeding.

Progestin/progesterone IUD: These IUDs can be used to try to minimize or stop menstrual bleeding. Because the hormone is released directly into the uterus, this option can be helpful for women who may not do well with oral hormones.

GnRH agonist (i.e. Lupron): A GnRH agonist will stop the ovaries from producing hormones causing a pseudo, or chemically-induced, menopause. With this treatment option, the adenomyosis may cease to be symptomatic during the induced menopausal period. Additionally, periods should stop which will relieve bleeding related issues.

Ablation: During an ablation, the endometrium is removed from the uterus which can eliminate menstrual bleeding and pain. Women with minimal adenomyosis can benefit from this option, but it is less likely to be effective for those with deep adenomyosis.

Uterine Artery Embolization: Tiny particles can be inserted in the blood vessels leading to the area of adenomyosis. These particles can then cut the blood flow to the adenomyosis causing it to shrink.

Osada Procedure: This lesser-known procedure involves opening the uterus and radically removing the adenomyotic tissues. The uterus is then reconstructed. This procedure can allow for the removal of adenomyosis while retaining fertility.

Hysterectomy: This surgery is the most invasive treatment option. It is also the only definite way to eliminate adenomyosis permanently. It may be a choice for women who have extreme symptoms and who are no longer interested in fertility.

Adhesions are a type of scar tissue that has formed between two organs or tissues. These bands of scar tissue can form following a surgery, an infection, or any other trauma to an area. As the body tries to repair itself, cells may not recognize surrounding tissue and organs. Thus, as the healing organ comes in contact with another organ or tissue, the body attempts to repair both organs, causing the two areas to become connected. Over time, those adhesions can shorten and possibly cause pain, digestive issues, infertility, and painful intercourse as the affected organs are moved and distorted.

Women with unexplained chronic abdominal or pelvic pain should be evaluated for adhesions. This is especially true for women with a history of abdominal or pelvic surgeries including C-sections, appendectomies, and laparoscopies. Women with endometriosis are also more prone to have adhesion formation. Cancer and resulting treatments may also lead to adhesions.

Diagnosing adhesions without surgery can be difficult and may be the result of excluding other conditions. In their initial stage, adhesions are like filmy spider webs that are not detected on CT scans, X-rays, ultrasounds, or other tests. In later stages, the adhesions may become more dense and, thus, more visible. They can also cause a bowel obstruction which could be noted on various tests. Distorted organs or organs in an unusual location as a result of adhesions may also be noted on some tests. To help with diagnosis, women with chronic pelvic pain should keep a detailed symptom diary.

Women with suspected adhesions should look for a doctor who primarily treats women with chronic pelvic pain issues. This type of physician is not likely to practice obstetrics. Another option could be a physical therapist who practices deep tissue massage; gently breaking up the adhesions could offer symptom relief.

Painful adhesions involving the uterus may, at times, lead to a hysterectomy. However, a gynecological surgeon trained in minimally invasive surgery may be able to treat the adhesions while preserving the uterus. A skilled general surgeon may also be able to perform uterus-sparing surgery. Unfortunately, any surgery performed to treat adhesions can allow for the formation of new adhesions. In some cases, a type of adhesion barrier may be used to try to prevent new adhesions. Surgeons with adhesion experience may also use special surgical methods to try to help minimize the formation of new adhesions.

Before scheduling a hysterectomy to treat adhesions, the seek a second opinion. If there is an underlying cause for adhesions, that condition needs to be treated as well. Otherwise, adhesions and subsequent symptoms could continue despite the hysterectomy. If surgery is necessary, some type of laparoscopic procedure could offer the most optimal outcome, whether or not it includes removal of the uterus.

Cervical cancer is the second most common cancer in women worldwide. It is the only gynecological cancer that can be prevented through regular screening. Cervical cancer starts out as abnormal cellular changes in the cervix, the part of the uterus that opens to the vagina. Cervical cancer is slow-growing and can be caught early with regular Pap tests.

Risk Factors and Prevention
Since most cases of cervical cancer are caused by the human papilloma virus (HPV), cervical cancer can now be prevented for most women by getting the HPV vaccine between the ages of 9 and 26. For those who did not get the vaccine and were exposed to HPV (an extremely common STD), annual Pap tests should identify cellular changes in cervical tissue before they become cancerous. Other risk factors include smoking, HIV infections, and beginning sexual intercourse at a young age. So prevention should include educating girls and young women about the risks of sexual activity. Smokers should quit smoking.

Symptoms
Common symptoms of cervical cancer include bleeding after intercourse, excessive discharge and abnormal bleeding between periods, pelvic pain, bleeding after menopause, painful urination, and back pain. In its early stages, however, there are usually no signs or symptoms, which is why regular screening is important to detect it.

Prognosis
The earlier cervical cancer is detected, the better the chances of treating it successfully. Once it spreads to other parts of the pelvis or abdomen, it gets much harder to treat.

Treatment
If cervical cancer is caught early, it can be treated with radiotherapy, cryotherapy, laser treatment, or chemotherapy, and it may be possible to remove all the cancerous tissue in one treatment if the cancer is confined to the cervix. Later stages of cervical cancer involve other organs and will require more aggressive treatments, including hysterectomy, removal of other organs, and extensive chemotherapy.

Endometrial cancer, a type of uterine cancer, is cancer of the uterine lining, or endometrium. It begins when cells in the endometrium multiply out of control. They may invade the muscle of the uterus and sometimes spread to other organs and lymph nodes. Endometrial cancer is the most common gynecologic cancer. Most cases occur after menopause.

Risk Factors and Prevention
Obesity, hypertension, and diabetes are risk factors for developing endometrial cancer. Other risk factors include using estrogen without progesterone, tamoxifen use, and late menopause. Childlessness also seems to be a contributing factor. Keeping blood sugar and blood pressure under control may help lower a woman’s risk of developing endometrial cancer, as can exercising, eating a healthy diet, and maintaining a healthy weight.

There is no routine screening test for endometrial cancer. If a woman has extremely heavy bleeding during menstruation or any bleeding after menopause, an endometrial biopsy or D&C should be performed.

Symptoms
Symptoms of endometrial cancer include bleeding after menopause, or irregular or heavy bleeding in younger women. Other symptoms might include painful urination, pain during sexual intercourse, or generalized pelvic pain.

Prognosis
As with all cancers, the earlier uterine cancer is detected, the better the outcome is likely to be. There is a wide range of stages and grades of endometrial cancer, so the prognosis depends on each woman’s diagnosis and how aggressively the medical team treats it. Prognosis is determined by the stage of the cancer, how the cancer cells look under a microscope, and whether the cancer cells are affected by progesterone.

Treatment
Treatment options include surgery, radiation, and hormone therapy. Surgery to treat endometrial cancer will most likely involve a total hysterectomy. A radical hysterectomy will be recommended if the cancer has spread beyond the uterus. Radiation therapy might be in the form of external pelvic radiation or internal radiation. Hormones can cause cancer cells to grow and multiply, so hormone therapy is meant to block hormonal action and thereby shrink or stop uncontrolled cellular growth in the endometrium.

Ovarian cancer usually starts in epithelial cells on the surface of an ovary. It is the seventh most common cancer among women, and it is the fifth leading cause of cancer deaths among women worldwide. It is difficult to detect early since its symptoms can mimic other pelvic diseases, and the ovaries are not easily accessible for inspection or testing.

Risk Factors and Prevention
A family history of ovarian cancer is the most important risk factor. The risk of OC increases with age. It is particularly likely around the time of menopause. Childlessness is also a factor. Birth control and pregnancy reduce the risk of OC. There is no effective screening test for OC. If you have a family history of OC, you can have a CA-125 blood test to check for the presence of the genetic marker. But the CA-125 test has been known to produce false positives, and it does not necessarily indicate that you have OC, so it is a poor screening method. You can also undergo a transvaginal ultrasound to see if there are any visible masses on your ovaries. For those at high risk of OC, a biopsy is the best way to check if there is any question about the possibility of cancer.

Symptoms
Common symptoms of ovarian cancer include bloating, pelvic or abdominal pain, difficulty eating, or feeling full quickly. Other symptoms that often accompany OC include fatigue, indigestion, back pain, pain with intercourse, constipation, and menstrual irregularities. The more of the first set of symptoms a woman has at the same time, the more urgent it is for her to see a doctor to check for OC. The second set of symptoms is less useful in diagnosing OC, except when they occur with multiple occurrences of the first set of symptoms for an extended period of time.

Prognosis
The earlier ovarian cancer is detected, the better the chances of treating it successfully. Unfortunately, most cases of OC are detected at stage 3 or beyond, which means that it has spread to other organs and lymph nodes by the time it is diagnosed. The prognosis is still relatively positive, though, with an aggressive treatment plan.

Treatment
The three standard treatments for ovarian cancer include surgical removal of cancerous organs and tissue, radiation therapy, and chemotherapy. Depending on the stage of your cancer, your surgeon may remove one or both ovaries, your uterus and one or both ovaries, or your entire reproductive system. Newer treatments include biologic therapy (a type of immunotherapy) and targeted therapy (uses drugs that find and attack cancer cells without harming normal cells). These are still in clinical trials, in which OC patients—particularly those in later stages—are encouraged to consider participating.

A sarcoma is a malignant tumor that develops from bone or soft tissue such as fat, muscle, nerves, fibrous tissues, blood and lymph vessels, or deep skin tissues. Uterine sarcomas are a type of soft tissue sarcoma that forms in the muscle or supporting tissues of the uterus. These sarcomas make up about 2–4% of uterine cancers in the United States and less than 1% of all gynecologic malignancies (a). They are classified into these categories: uterine leiomyosarcomas, endometrial stromal sarcomas, undifferentiated sarcomas, carcinosarcomas, and adenosarcomas (b).

Symptoms of uterine sarcomas can vary and are similar to some non-cancerous conditions. In the earliest stages, they may not show any symptoms at all. If you experience any of the following symptoms, don’t panic, but do start working with your physician to determine their cause:

• Abnormal bleeding or spotting
• Post-menopausal bleeding
• Vaginal discharge
• Pelvic pain
• Pelvic fullness
• Pelvic mass
• Frequent urination

To help determine if you may have a uterine sarcoma, your physician should do a complete physical and pelvic exam in addition to a thorough review of your symptoms, risk factors, and personal and family medical histories. Your physician may also recommend various tests, including an endometrial biopsy, hysteroscopy, or dilation and curettage (D&C) for a tissue sample. If there’s a chance that the bladder or rectum is involved, you may also need a cystoscopy or proctoscopy. Ultrasound, CT scan, CT-guided needle biopsy, MRI, and/or a PET scan may also be ordered. You may even need a chest x-ray if there is any suspicion that the tumor has metastasized to the lungs.

Because uterine sarcomas are rare and symptoms can vary, expert pathology is critical for diagnosis. If the tissue sample looks normal, it can indicate a lower grade of cancer. The rate at which the cells appear to be growing is another factor used when grading sarcomas. Tissues may also be tested to determine if they contain estrogen and/or progesterone receptors to help determine if treatment with drugs that affects those hormones could be helpful.

Treatment can include surgical removal of the uterine sarcoma through laparotomy, hysterectomy, oophorectomy, salpingectomy, and/or lymphadenectomy. Radiation, chemotherapy, and/or hormone therapy may also be used. Joining a clinical trial is a way to try newer treatment options being explored.

As with all cancers, prognosis is highest when uterine sarcomas are diagnosed in the earliest stage, but it can also depend on the location, size, and type of tumor. Unfortunately, sarcomas can reach an advanced stage before they cause any symptoms that would lead to a diagnosis. As such, if you have any concerns or a family history of sarcomas, you should speak to your physician as soon as possible.

If uterine sarcoma is suspected, it is wise to consult with a gynecologic oncologist who specializes in cancers involving the female reproductive system. Because uterine sarcoma is rare, it may be beneficial to visit a large, well-established cancer facility.

(a)ASCO-Uterine Cancer
(b)ACS-What is uterine sarcoma?

Vaginal cancer occurs when malignant cells form in the vagina. This form of cancer is very rare, but there are several types of vaginal cancer:

• Vaginal squamous cell carcinoma: squamous cells line the surface of the vagina. Cellular changes over a period of years could become a cancerous issue. This type of cancer normally exists near the cervix. About 70% of vaginal cancer is squamous cell carcinoma.
• Vaginal adenocarcinoma: this type of cancer is known as adenocarcinoma and usually develops in women over 50. This cancer begins in the gland cells and comprise about 15% of vaginal cancer cases.
• Vaginal melanoma: vaginal cancers that develop in the pigment-producing cells (melanocytes) are known as melanomas. These usually develop in the lower or outer portion of the vagina. Only about 9% of cases are melanomas.
• Vaginal sarcoma: cancer beginning in the connective tissue, muscle, or bone is known as sarcoma. This can develop deep in the vaginal wall. With only up to 4% of vaginal cancer cases in this category, it is the rarest form of vaginal cancer.

Risk Factors and Prevention
Most cases of vaginal cancer occur in women over 60. Less than 15% of women under 40 will be diagnosed with this type of cancer. Daughters of women who used DES (diethylstilbestrol), the drug given during the 1950s to prevent miscarriages, may have a slightly higher risk of vaginal cancer. Vaginal intraepithelial neoplasia (VAIN) caused by human papillomavirus (HPV) can also increase the risk of vaginal cancer. Other risk factors include having cervical cancer or human immunodeficiency virus (HIV). Use of alcohol and cigarettes may also increase the risk of vaginal cancer. Preventive steps can include limiting sexual partners, being vaccinated for HPV, limiting alcohol intake, stopping smoking, and undergoing regular pelvic exams.

Symptoms
In it earliest stages, vaginal cancer may not exhibit symptoms. However, it could be detected during a routine Pap test or pelvic exam. As the cancer develops, women may experience bleeding or discharge, pain with intercourse, pelvic pain, and/or a vaginal lump. Bleeding after menopause, painful urination, and constipation may also be symptoms.

Prognosis
Though this type of cancer is rare, it has a high cure rate when diagnosed early. Unfortunately, early stages of this cancer may be asymptomatic. Vaginal cancer that has spread outside the vagina can be difficult to treat.

Treatment
Early stage vaginal cancer limited to the surface of the vagina may be excised. Laser surgery or topical therapy may also be options at this stage. For more invasive cancer, chemotherapy, radiation, and/or invasive surgery may be necessary. Later stages may require not only the removal of the vagina, but also the removal of other pelvic organs.

Most ovarian cysts are harmless and resolve on their own. Depending on symptoms, initial treatment may only require a watch and wait approach. In other cases, symptoms and pain may require medical or pharmaceutical intervention. Cysts in menopausal women may be treated more quickly and aggressively because they may have a higher malignant risk.

A functional cyst forms on the surface of the ovary during the normal monthly menstrual cycle. At the time of ovulation, the cyst opens and releases the maturing egg. If the cyst does not open to release the egg, it can fill with fluid forming a follicular cyst. A corpus luteum cyst can occur if the egg has been released but the cyst closes again.

Complex ovarian cysts may require an oophorectomy (removal of the ovary) because the ovary can be damaged either by the cyst or from the surgery to remove the cyst. Complex cysts include demroid cysts, cystadenoma, and endometriomas. These types of cysts are normally benign.

In some cases, surgery may be required to treat a cyst. In general, the uterus does not play a part in the formation of cysts or the treatment of them. Thus, even if surgery is required, a hysterectomy is usually not necessary to treat ovarian cysts. There can be exceptions, however, including the case of cancer or when both ovaries have been destroyed.

If there is a cancer concern, or you are menopausal, your doctor may be more likely to recommend an oophorectomy. Depending on your risk factors, removal of both ovaries may be also be suggested. Cancer concerns may also dictate the removal of the uterus to minimize cancer spreading to that organ.

If both ovaries will be removed, a hysterectomy may also be recommended. The hormones produced by the ovaries allow the endometrium to thicken and shed each month. Without the ovaries to produce the necessary hormones, the endometrium can thicken without shedding creating an endometrial cancer risk. In lieu of a concurrent hysterectomy, women may be able to use both estrogen and progesterone replacement therapy, cycling the progesterone to force a period. Women who choose this option must be diligent with their hormone therapy and annual or bi-annual medical exams.

Before consenting to a hysterectomy to resolve ovarian cyst concerns, seek a second opinion. If there is a cancer concern, consult with a gynecological oncologist. There are a wide variety of options for treating ovarian cysts that do not necessitate a hysterectomy.

Endometriosis is a very complex and often misunderstood medical condition that affects an estimated 10% of all women worldwide who are in their reproductive years. With endometriosis, tissue similar to the endometrial lining implants in various areas of the body though primarily in the pelvic region. More common locations for endometriosis lesions are the ovaries, fallopian tubes, peritoneum (pelvic side wall), outside of the uterus, cul-de-sac, bowel, bladder, rectum, appendix, ureters, and urterosacral ligaments. More rarely, other areas of the body can be affected from the vagina to the brain.

Most often, women with endometriosis complain of pain. While the pain can be cyclic, it can also occur throughout the month. Women with endometriosis may also have issues with pain during bowel movements (dyschezia), pain with intercourse (dyspareunia), pain with urination (dysuria), and pain before or during her menstrual cycle (dysmenorrhea). Pain from endometriosis can be mild to severe and the stage of endometriosis does not correlate with the severity of symptoms. Additionally, women with endometriosis can be asymptomatic.

Diagnosis

At this time, laparoscopy is the most definite way to diagnosis endometriosis. In general, endometriosis implants are too small to be seen on any type of imaging test and there are no blood tests to indicate its presence.

Keeping a symptom diary detailing your symptoms can help you and your doctor determine if a laparoscopy to diagnosis and possibly treat endometriosis would be appropriate.

Treatments

The treatment options offered to you can depend on the skill and knowledge of your doctor and your specific symptoms. Your fertility concerns should also be taken into consideration. Treatment can range from pain medications to hormone therapy to surgery.

Pain medications can include over the counter pain medications, NSAID’s, or narcotics. These only treat the symptoms of endometriosis but do not treat the actual lesions.

Hormone therapy can include birth control pills, the Mirena IUD, GnRH-agonists, Danazol, or progesterone/progestin.

Surgical options include a laparoscopy for diagnosis and treatment, and in some cases a hysterectomy and/or oophorectomy though removal of the uterus and/or ovaries does not cure endometriosis.

Abnormal or dysfunctional bleeding can be caused by hormone issues, polyps in the uterus and/or cervix, endometrial hyperplasia, and other conditions including fibroids, adenomyosis, pelvic infection, and uterine or cervical cancers.

Bleeding can range from light to heavy. It may be simply an inconvenience or it may interrupt your daily activities, especially if it’s associated with pelvic pain and uterine cramping. Fortunately, there are several treatment options, both surgical and non-surgical.

Non-Surgical Treatment Options

• Hormones to regulate ovulation and menstruating for hormone related bleeding
• Progestin-containing IUD (Intrauterine device) for endometrial hyperplasia.

Surgical Treatment Options

• Endometrial ablation: removal of uterine lining by rollerball or rollerbarrel, thermal balloon, or freezing
• Hysterscopy for removal of polyps in uterus and/or cervix
• Hysterectomy: removal of uterus

A hysterectomy is used to treat abnormal uterine bleeding only when other approaches have failed.

Uterine fibroids are a common diagnosis for women and are almost always benign (non-cancerous). As women grow older, they are more apt to develop a fibroid with many sources suggesting that up to 50% of all women will develop a fibroid by the age of 50. Women in their 40’s and early 50’s are more likely to be diagnosed with fibroids than women in their 20’s and 30’s. Fibroids account for about one third of all hysterectomies performed each in year in the United States. Not all fibroids cause symptoms but when symptoms occur they can negatively impact a woman’s quality of life. Women may have one fibroid or multiple fibroids.

The medical term for fibroid is leiomyoma, a type of myoma tumor. They are tumors of the smooth muscle of the uterus and contain muscle tissue. Fibroids are classified according to their location in the uterus.

• Submucosal–this type of fibroid grows into the cavity of the uterus and distorts it.
• Intramural or Myometrial–these fibroids grow in the wall of the uterus but do not distort the cavity of the uterus.
• Subserosal–this fibroid grows on the surface of the uterus.
• Pedunculated–these fibroid grow from a stalk either inside or outside the uterus.

Causes and Risks

The cause of fibroids is unknown though there may be a genetic connection and hormones affect them. Fibroids rely on both progesterone and estrogen for growth causing them to grow rapidly during pregnancy and shrink during menopause.

Besides a family history, risk factors include obesity, never having given birth, hypertension, beginning menstruation before age 10, and being of African heritage.

Symptoms

Women with fibroids may experience several different symptoms. Menstrual bleeding can become heavy and last seven days or longer. Pain may occur during intercourse. Leg pains and lower backache may occur. There can be a feeling of pressure or heaviness in the lower pelvic region as well as bloating and swelling in this area. Some women experience bladder concerns including frequent urination and trouble emptying the bladder. There can also be issues with fertility and pregnancy.

Diagnosis

There are several ways to diagnosis fibroids. During a routine pelvic exam, your surgeon may notice abnormalities in the shape of your uterus. An ultrasound can then be used to confirm the diagnosis. At times, a CT scan or MRI may be needed to confirm diagnosis or make determinations for surgery.

To evaluate the extent of a submucosal fibroid, your doctor may order a hysteroscopy or sonohysterography. During a hysteroscopy, your doctor can look inside your uterus using a hysteroscope (lighted telescope). Saline will be used to expand your uterus to allow the doctor to see more clearly. During a sonohysterography, saline is used to expand the uterus for ultrasound images.

Another test that may be recommended is a hysterosalpingogrpahy. For this test, dye is used to highlight the uterus and fallopian tubes for an x-ray.

A laparoscopy may be suggested if a fibroid is suspected on the outside the uterus. During this surgery, a laparoscope (thin scope with a light and camera) is inserted into a small incision often in the belly button. This allows the doctor to look around the outside of the uterus and take pictures.

Fibroids Treatments

There are many treatment options available for fibroids from doing nothing to having a hysterectomy. Treatment can depend on the type of fibroid, number of fibroids, your age, fertility concerns, and any symptoms you may be having.

Several medications may be used to treat fibroid symptoms. If the primary issue is heavy bleeding, hormonal options such as birth control pills can be a good choice. GnRH agonists such as Lupron can be used to stop heavy bleeding as well as attempt to shrink the fibroid. With an IUD, pain and bleeding issues could be addressed.

There are also outpatient procedures that may be an option. During an ablation, the endometrium and any fibroids within the uterus can be removed. This eliminates heavy bleeding as well as the fibroid(s). During either a Uterine Fibroid Embolization (UFE) or Uterine Artery Embolization (UAE), particles are inserted in the blood vessels suppling the fibroid in order to stop the blood supply to the fibroid. As a result, the fibroid shrinks. Myolysis involves inserting a needle into the fibroid and destroying it with either heat or cold. MRI-guided focused ultrasound surgery (MRgFUS) uses MRI guided ultrasound to heat the fibroid and cause its cells to die.

More invasive surgical options include a myomectomy or hysterectomy. During a myomectomy, the fibroid is cut from the uterus and the uterus is then stitched closed. A hysterectomy involves the removal of the uterus with the fibroids. Though this procedure is the only definite way to cure fibroids, it comes with several risks, involves the removal of an organ, and ends the ability to every conceive and carry a child.

Your genetics could affect when you start menstruation and when you enter menopause. They may also play a role in your risk for certain gynecological conditions and how you manage them. Knowing your family medical history in conjunction with any symptoms you may have can help you and your medical team make better decisions about your health. If multiple members of your family share similar medical problems, talk to your doctor about the possibility of genetic testing. For instance, BRCA 1 and BRCA 2 testing could help you determine your risks for breast and ovarian cancer. Testing can also be done to check for the mutations that may lead to Lynch Syndrome. Working with a genetic counselor could help you determine what testing is best, and may help you make better decisions once you have the test results.

Genetics may play a role in gynecological conditions such as:

• Endometriosis
• Breast Cancer
• Ovarian Cancer
• Lynch Syndrome
• Polycystic Ovary Syndrome (PCOS)
• Uterine Fibroids

Additionally, there are pregnancy-related concerns that can be linked to genetics. These include:

• Pre-eclampisa
• Placental abruption
• Gestational diabetes
• Intrahepatic cholestasis of pregnancy

Furthermore, exposure to DES (diethlstibestrol) while in the womb can lead to the following gynecological issues:

• Vaginal adenosis
• Reproductive abnormalities
• Clear cell adenocarcinoma (CCA)
• Cervical intraepithelial neoplasia (CIN)
• Breast cancer
• Infertility
• Pregnancy complications
• Pre-mature menopause

Genetic research is being done for DES granddaughters to determine if gene mutation occurred for their parent who was exposed to DES in the womb. If so, that gene mutation may have been passed on to the DES grandchild.

If you are concerned about genetic gynecological cancer risks, put on your brave face and start gathering resources:

• Your personal medical history
• Your family medical history
• A family or GYN doctor
• A Genetics counselor
• A support group of friends and family

Once you’ve armed yourself with these resources, the next step is vital. Your genetics risk will be your roadmap to making health decisions for you and your children and grandchildren. Be your own best advocate for your personal health now and in the future.

When fluid collects in a fallopian tube, it is called hydrosalpinx. Fallopian tubes are very delicate, and they can swell shut when injured, irritated, or infected. When both ends of a fallopian tube close, it fills with fluid and expands. The fluid eventually leaks out through the uterus and vagina, causing a clear discharge similar to what you describe.

Common causes of infection or injury to the fallopian tubes include pelvic inflammatory disease, sexually transmitted diseases, endometriosis, IUDs, and injury or adhesions from abdominal surgeries. Cancer is also a possibility and should be ruled out, but it is not a common cause of hydrosalpinx.

Hydrosalpinx usually affects both fallopian tubes and can often be detected with an ultrasound, particularly if it very distended (swollen). A hydrosalpinx can grow to several centimeters in diameter, and such swelling would be easy to see on an ultrasound. However, if the hydrosalpinx is still small and is not detected with an ultrasound, your doctor may go on to run an x-ray scan with contrast, which is called a hysterosalpingram (HSG), to see if fluid is collecting in one or more fallopian tubes and failing to drain into the uterus. If that test is unsuccessful and your doctor still suspects a fluid-filled fallopian tube, he or she may perform a laparoscopy to insert a tiny camera into your abdomen to take a look at the fallopian tubes firsthand.

Once hydrosalpinx is positively diagnosed and other conditions are ruled out, there are three main treatment options: physical therapy (massage to help open the tubes and release the fluid), salpingostomy (putting a small hole in the tube to drain it), or salpingectomy (surgically removing the fallopian tubes).

Hydrosalpinx can cause excessive discharge, abdominal pain, and infertility. The only preventive measure you can take is avoiding contracting STDs and treating pelvic infections promptly with antibiotics. Once the damage is done to the fallopian tube(s), it is often irreversible.

It is a great idea to seek a second opinion in cases like these. Some doctors are quick to recommend a hysterectomy for virtually any gynecological problem. But in this case, if the second physician is correct, you may be able to solve the discharge problem and keep your uterus and ovaries intact.

Endometrial hyperplasia is an abnormal overgrowth of the endometrium (lining of the uterus) resulting from prolonged stimulation by estrogen without the proper changes in progesterone levels to trigger regular menstrual bleeding. This causes the endometrium to thicken and become glandular. This is hyperplasia, which may also be a premalignant lesion. In other words: it is not cancer, but it may be a precancerous condition. In about one in four cases, these lesions do become cancerous, so it is certainly something to take seriously.

There are four types of endometrial hyperplasia, some more concerning than others.

Hyperplasia can be either simple or complex. Simple hyperplasia usually refers to the buildup of extra cells in the endometrium without other changes in the structure of the uterine lining. Complex, or glandular, hyperplasia includes both a buildup of cells and the formation of glandular tissue. Women are more susceptible to both forms of hyperplasia during perimenopause, the years just prior to menopause, when menstruation becomes irregular. Post-menopausal women on hormone replacement therapy also have an increased risk for developing hyperplasia.
Atypia refers to the presence of abnormal, possibly precancerous cells in your biopsy. The presence of atypia increases the chance that hyperplasia will develop into malignant tumors.

Simple and complex hyperplasia without atypia together carry just a 3% risk of developing into endometrial cancer. This is about the same risk as a woman without hyperplasia, so hyperplasia without atypia is not considered a precancerous condition. Most gynecologists will recommend treating these conditions with progestin therapy to trigger the sloughing off of the endometrial lining as occurs during regular menstruation.

Hyperplasia with atypia, however, is considered precancerous. The presence of atypical cells means that you and your doctor will want to treat your hyperplasia more aggressively and keep a careful eye on its development. Simple hyperplasia with atypia can be treated with progestin therapy and has a less than 10% chance of developing into cancer. Complex hyperplasia with atypia, though, carries a 25–30% chance of developing into cancer, and in some cases preexisting cancerous cells are detected during treatment. The more advanced and severe the atypia is, the more likely it is to develop into cancer. Many gynecologists will recommend hysterectomy for complex hyperplasia with atypia.

Interstitial cystitis (IC) patients often experience pressure, tenderness, or pain in the bladder and pelvic area. Symptoms may also include urinary frequency (of up to 60 times a day), increase nighttime voiding (nocturia), sudden moments of urgency (the I’ve got to go NOW feeling) and discomfort associated with sexual relations. Many patients notice that their pain worsens as their bladder fills with urine that is relieved after voiding. However, some patients just feel pelvic pain that they are convinced is coming from their reproductive tract.

In IC/PBS, the bladder wall is usually very irritated, inflamed and/or injured. When doctors examine the bladder wall, may find glomerulations (pinpoint bleeding caused by recurrent irritation). Larger, more painful wounds (Hunner’s ulcers) are present in 10 percent of patients with IC.

To reduce inflammation, IC patients may use an antihistamine (such as hydroxzyine) to help reduce mast cell activity. They may use a protective coating (such as rescue instillations, elmiron or sodium hyaluronate) that can cover up the wounds in the bladder so that they are not irritated each day by urine. A low dose antidepressant can reduce neuroinflammation in the pelvis. If pelvic floor dysfunction (aka very tight painful muscles) and/or trigger points are present, then physical therapy is used. Several over the counter supplements have also gained in popularity, particularly products which use quercetin (such as Cystoprotek, Algonot, CystaQ or Bladder Q).

IC patients may struggle with other related disorders that can make diagnosis more difficult. Irritable bowel syndrome is a common complaint, as well as pelvic floor dysfunction, vulvodynia, chronic pelvic pain, allergies and anxiety disorder. Sadly, many patients have endured unnecessary surgeries, such as an unnecessary hysterectomy, before their interstitial cystitis was properly diagnosed.

If your doctor suggests a hysterectomy because of your ongoing migraines, this is probably the best time to talk to another doctor or two about your options. Time for a second opinion!

If your doctor believes your migraines are due to hormones, it is possible to find treatments that help to level out your hormones.

Simply removing your uterus does not change your hormone levels in your body. If the thinking is to remove the ovaries and replace your hormones with Hormone Replacement Therapy (HRT) to stabilize fluctuating hormones, this may sound sensible. Or does it?

Removing an organ (or organs) to replace them with a substandard, not-the-same-as-what-your-body-makes-naturally can be a risk. Creating a situation to induce surgical menopause can be swapping one migraine for a lifetime of other symptoms that are not easily treated.

If you were to take a poll of the women who had hysterectomies, you would find that they if they had migraines before their surgery, they are likely to have them after their hysterectomy. Some many benefit as a side note for decreased incidences of headaches but for others, they have increased migraines with the addition (or missing) hormone replacement therapy (HRT).

It would be better to locate the cause of your migraines and treat the cause instead of removing organs which may not be the culprit at all. Visit with other doctors who specialize in migraines and treatments.

Painful intercourse, or dyspareunia, can occur for a number of reasons. Whether or not a hysterectomy will alleviate your issues will depend on the reason(s) for your symptoms.

Pain during intercourse that occurs with entry may be related to a number of issues. These can include a lack of adequate lubrication, vaginismus, inflammation, infection of the genital area or urinary tract, skin disorders, an injury, or prior trauma. As the uterus does not cause or affect any of these issues, a hysterectomy is not a likely solution for any of these concerns.

If pain occurs with deep intercourse, the issue could be the result of a wide variety of gynecological conditions. These can include endometriosis, fibroids, pelvic organ prolapse, a retroverted uterus, pelvic inflammatory disease (PID), or ovarian cysts. In some cases, a hysterectomy could alleviate these sources of pain. For instance, removing the uterus would eliminate uterine prolapse and retroverted uterus concerns. On the other hand, a hysterectomy does not cure endometriosis, and PID can occur post hysterectomy. For these conditions, it depends on the extensiveness of the disease as to whether or not a hysterectomy would be a possible solution. Depending on the location and type of fibroids, there can be treatment options besides a hysterectomy you can consider. Removing the uterus would not address issues involving ovarian cysts.

Hormonal imbalance issues can also cause painful intercourse. If the issue is a result of vaginal dryness and thinning tissues caused by no or low estrogen, a more appropriate course of treatment would involve some type of estrogen therapy. A hysterectomy could actually worsen any hormone-related issues.

There are non-gynecological reasons for painful intercourse as well. These can include irritable bowel syndrome (IBS), interstitial cystitis (IC), adhesions, and physiological concerns. None of these issues can be resolved with a hysterectomy. Instead, each condition would need to be treated individually. Counseling could also be beneficial.

Because there are so many reasons for painful intercourse, it is wise to keep a detailed symptom diary that you and your medical team can review. This will help you determine the cause of the pain and the best course of treatment. Seek a second opinion, preferably from a doctor who does not practice obstetrics. Both a gynecologist who specializes in pelvic pain or a uro-gynecologist could be good choices. Additionally, finding a doctor who has a special interest in sexual dysfunction could help with proper diagnosis and treatment.

A hysterectomy should be a last resort option for dyspareunia, especially if there is no diagnosed reason for the pain. Most reasons for painful intercourse are unrelated to the uterus, and thus a hysterectomy may be of little help. If the cause of the pain is determined to be uterine related, then a hysterectomy could be considered as an option after other less invasive options have been tried.

Pelvic Inflammatory Disease (PID) is a serious infection of a woman’s pelvic organs that occurs when bacteria has passed from the vagina through the cervix, into the uterus, fallopian tubes, and/or ovaries. Most cases of PID are caused by gonorrhea or chlamydia, two sexually transmitted infections (STIs). However, PID can also occur without the presence of an STI. PID may occur following douching, an IUD, an abortion, pelvic procedures and surgery, and sometimes childbirth.

Symptoms of PID can include pelvic tenderness and pain, abnormal vaginal discharge, irregular periods, chills and fever, nausea and vomiting, and painful intercourse. Diagnosis of PID can be done based on symptoms, pelvic exam, testing for STIs and a UTI, ultrasound, endometrial biopsy, and/or laparoscopy.

PID can cause permanent damage to the reproductive organs including scarring and blockage of the fallopian tubes and scarring around the uterus, fallopian tubes, and ovaries. PID can also lead to infertility and an increased risk of an ectopic or tubal pregnancy.

Treatment of PID begins with antibiotics either orally or intravenously in a hospital setting and may be the only treatment required. If extensive adhesions have formed that cause symptoms, surgical treatment may be necessary to remove them. Depending on the damage to the organs involved, at times a hysterectomy, salpingectomy, and/or oophorectomy may be required.

It is important to note that PID can occur/reoccur following a hysterectomy.

Pelvic Congestion Syndrome (PCS) is a condition that seems to affect multiple veins in the pelvic region and can be the cause of chronic pelvic pain women. PCS is similar to varicose veins in the legs. In both situations, valves in the veins which help blood flow toward the heart are weak or damaged. Because the function of the valves is to prevent a backflow of blood, pooling can occur in the veins when the valves are not working properly. This pooling of blood allows the veins to become stretched and engorged. With PCS, the veins involved are located near the fallopian tubes, ovaries, uterus, vulva, and vagina.

Women with PCS may have symptoms that can include dull pelvic pain, pressure, and heaviness. Pain can increase with long periods of standing, at the end of the day, with sexual intercourse, and at the onset of the menstrual period.

There are several tests which can be done to diagnose PCS. Often, an ultrasound will be ordered first and a pelvic venogram, CT Scan, and/or MRI may follow.  Laparoscopy can also be performed to help with diagnosis and to rule out other conditions which could be causing the symptoms.

Once a diagnose of PCS has been reached, there are several treatment options to consider. Embolization by an interventional radiologists is a minimally invasive option that has been used in the last decade to close off the faulty vein. In some cases, surgical ligation and stripping (tying off and removing) the problematic vein may be possible. Other alternatives include physical therapy, transcutaneous electrical nerve stimulation (TENS), trigger point injections, epidural and spinal nerve blocks, and acupuncture. If the problematic veins involve the uterus, a hysterectomy may be considered if other treatment options fail. Likewise, if the veins involve the ovary, an oophorectomy may be considered if other treatment options fail.

In general, medications are not used to treat PCS. However, pain medications may be needed to manage the pain. Additionally, antidepressants have been used successfully to manage both the chronic pain and depression that can occur as a result of the pain and symptoms. Hormonal medications may be used to stabilize hormones which can help with PCS.

In some cases, doctors will try medications to suppress ovarian function hoping that by stopping menstruation symptoms will be better controlled.

A hysterectomy should be a last resort option for treating varicose veins in the pelvic region. There are other less invasive treatment options which should be tried first. Before scheduling a hysterectomy for pelvic congestion syndrome, it can be helpful to schedule a second opinion. An interentional radiologist may be your best choice as this type of doctor can use minimally invasive options to treat the specific varicose veins which are causing your symptoms rather than remove your reproductive organs.

Polycystic Ovarian Syndrome/Disorder (PCOS) is a disorder of the endocrine system. While one of the symptoms can be polycystic ovaries, it is only one of many symptoms. Some women have polycystic ovaries, but do not have PCOS. Other women have PCOS, yet do not have polycystic ovaries. Unfortunately, at this time there is no cure for PCOS.

An oophorectomy will obviously put an end to polycystic ovaries by removing them. It will not alter the other symptoms, which can include insulin resistance. If you were suffering from other symptoms before your surgery, they will remain after your surgery. One possible exception is that since the ovaries produce up to 60% of your body’s testosterone, when they are removed, it may be enough of a decrease in androgens to no longer cause unpleasant side affects.

Are there any special HRT requirements after an oopherectomy?

There has been very little, if any research concerning PCOS and HRT therapy after an oophorectomy. From experience, we see that it can take longer for the woman with PCOS to attain a balance of their hormones. This is because of other issues with additional hormones which may also need to be addressed. One thing that seems to be agreed upon by all is that the woman with PCOS should rarely be given testosterone or DHEA supplements.

It is very important that the woman who has PCOS find a doctor who understands PCOS and surgical menopause. Not everyone in the medical community is up-to-date with the latest research and treatment options. It is important to get treatment for insulin resistance.

There can be several reasons for post menopausal bleeding, some more serious than others. Regardless, bleeding after menopause is not considered normal and requires immediate medical attention. Depending on the cause of your bleeding, there may be treatment options besides a hysterectomy. The sooner you seek treatment, the more options that may be available for you.

The most common reasons for post menopausal bleeding include fibroids, issues involving the endometrium, cancer concerns, hormonal issues, infection, pelvic trauma, bladder problems, and medications. In some cases, more aggressive surgery, such as a hysterectomy, may be necessary. For others, a change in medication or a type of hormonal treatment may be adequate for stopping the bleeding.

Depending on their location, polyps and fibroids may be treated or removed without a hysterectomy. Hormonal issues may be resolved with hormone replacement therapy (HRT). An antibiotic could clear up an infection of the uterus or urinary tract. If a medication, such as a blood thinner, is the problem, a simple change in prescription could be the solution.

Treatment for issues involving the endometrium can vary. If the problem is a thinning endometrium, using some type of estrogen might be the solution. On the other hand, if endometrial hyperplasia (thickened endometrium) is the cause of the bleeding, a progesterone or progestin could be necessary.

If cancer of the cervix, vagina, or uterus is suspected, you need to consult with a gynecological oncologist regarding the best treatment options for you. A cancer concern is the issue most likely to lead to a hysterectomy and needs to be treated aggressively by a knowledgeable medical professional. The longer you wait to seek treatment, the more aggressive and intense the treatments may be.

Once a woman has ceased to have a period for 12 months, she is considered to have completed menopause. At that time, no more vaginal bleeding should occur. If it does, seek medical attention immediately to determine what could be causing the bleeding and which treatment options are right for you. The sooner you seek treatment, the quicker the issue can be resolved, possibly in a minimally invasive manner. As always, be sure to seek a second opinion before scheduling any major procedure including a hysterectomy.

Post Ablation Tubal Sterilization Syndrome (PATSS) is a rare condition affecting some women who have undergone both endometrial ablation and tubal sterilization procedures. Those with PATSS can experience intense pain, vaginal bleeding, cramping, lower back ache, and painful intercourse. Pain and symptoms associated with the uterus could be resolved with a hysterectomy. However, some symptoms of PATSS involve the Fallopian tubes rather than the uterus.

According to one study, “The syndrome is caused by blood circulation problems in and around the Fallopian tubes and ovaries, pressure on nerves, and intrapelvic adhesion.” The Fallopian tubes of some women with symptoms of PATSS have been enlarged and swollen. Both acute and chronic inflammation have been found involving the tubes of women with PATSS. For these concerns, removing the uterus may have little to no affect. Instead, the solution could be a salpingectomy (removal of the Fallopian tubes) or reversal of the tubal ligation.

In other cases, women have been found to have endometrial scarring and/or myometritis, an infection of the muscular wall of the uterus. For these issues, a hysterectomy may be a possibility. Other less invasive treatment options could include antibiotics and pain medications.

Because the symptoms of PATSS can mimic other conditions, it is important for you and your physician to determine if there are other health concerns to consider. Keeping a detailed symptom diary can help you and your medical team more accurately determine what is going on. Conditions that need to be ruled out will include endometritis, tumors, and polyps.

Before scheduling a hysterectomy for PATSS, be sure to seek a second opinion. A gynecological surgeon who specializes in minimally invasive surgery may be able to help. Another option could be a gynecologist who specializes in chronic pelvic pain.

Premenstrual dysphoric disorder (PMDD) causes women to experience severe depression, irritability, tension and anxiety before menstruation. The symptoms of PMDD are more severe than those associated with premenstrual syndrome (PMS). There are a wide range of physical and emotional symptoms that can occur one to two weeks prior to the start of the monthly menstrual cycle, with most symptoms stopping shortly after the period begins.

The cause of PMDD is unknown. However, alcohol abuse, being overweight, eating disorders, large amounts of caffeine, smoking, lack of exercise, and having a mother with a history of the disorder could be contributing factors to PMDD.

There is some research that indicates PMDD may be the result of serotonin deficiency. Other research indicate the issue may be the interaction of hormones produced by the ovaries with the neurotransmitters (chemical that serve as messengers). Estrogen and progesterone levels for women with PMDD are the same as those without the disorder indicating the problem may be the brain’s response to normal hormone fluctuations during a menstrual cycle.

For this reason, the selective serotonin reuptake inhibitor class of antidepressants are effective for some women with PMDD.

Before considering surgery, other alternatives should be considered. Treatment options can include a healthy diet, exercise, vitamins and supplements such as B6, calcium and magnesium, birth control pills to top ovulation and regulate hormones, pain medications, anti-depressants, or medications to suppress the ovaries (Lupron, Depo Provera).

If a surgical procedure is being considered, one needs to carefully weigh the surgical pros and cons besides considering the possible effects for PMDD. Some women do find that using a steady does of HRT following a bilateral oophorectomy (removal of both ovaries) does resolve the majority of their PMDD issues while preventing many surgical menopause symptoms. However, finding the right HRT balance can be difficult for many. Also, an oophorectomy may not cure PMDD for everyone and it can open the door to surgical menopause health concerns that would need to be addressed.

If the uterus is not removed along with the ovaries, progsterone will be needed to insure that the endometrium does not thicken to unsafe levels, leading to a cancer concern. For some women, progesterone is part of the reason for PMDD issues so retaining the uterus might not be the right choice them.

It is important to find a knowledgeable physician to work with you through the options to determine what is best for you. Keeping a detailed symptom diary can be critical for helping you and your medical team monitor your symptoms to determine which choices are the right ones. A psychiatrist can also be a valuable member of your medical team through this process.

When the muscles and tissues supporting the bladder weaken or stretch, the bladder may fall from its normal position. This can cause it to press against the vaginal wall and even protrude into the vagina. A prolapsed bladder is known as a cystocele. There are several risks factors for a prolapsed bladder along with a variety of treatment options.

The supporting structures for the bladder can be compromised in many ways. These can include being pregnant and/or giving birth, being overweight, lifting heavy objects, straining, having a chronic cough, having inadequate estrogen, and/or having a genetic history of prolapse. If there is an underlying reason for your prolapsed bladder (such as low estrogen or constipation), it needs to be addressed along with the prolapse.

There are four grades of bladder prolapse:

• Grade 1/Mild: The bladder only falls slightly, so there may be no symptoms.
• Grade 2/Moderate: The bladder falls into the opening of the vagina, so symptoms are likely.
• Grade 3/Severe: The bladder protrudes through the vagina causing symptoms to increase. Women tend to experience pain and discomfort.
• Grade 4/Complete: The bladder falls outside the vagina worsening symptoms. At this stage women often experience other pelvic organ prolapses as well.

Women with bladder prolapse may experience pelvic pain or discomfort, lower back pain, and pain with intercourse. Urination issues can include incomplete voiding, difficulty urinating, and multiple bladder infections. Additionally, women with a cystocele may endure some embarrassing symptoms such as leaking urine when sneezing, coughing, or laughing. Finally, women may find they have a bulge in the vagina. Those with a mild cystocele may not have any noticeable symptoms, while those with a complete prolapse may experience multiple symptoms.

Your doctor may perform a variety of tests to help determine if you have a cystocele. For a moderate or complete prolapse, a pelvic exam conducted both lying down and standing may be enough for diagnosis. For less severe cases, other testing may be needed:

• Voiding Cystourethrogram: A series of X-rays taken during voiding.
• Urodynamics: This test measures the volume and pressure relationships in the bladder. This test is sometimes referred to as an EKG of the bladder.
• Cystoscopy: A scope is used to look inside the bladder.

Cystocele treatment options can depend on the grade of prolapse and symptoms. There are both surgical and non-surgical choices, but either way, you should avoid heavy lifting and straining to promote a successful treatment outcome.

Non-surgical:

• For early prolapse, a pessary may be effective. It is placed inside the vagina to hold the bladder in place.
• Vaginal estrogen may also be prescribed with a pessary, or another form of estrogen may be prescribed separately.
• Exercises and physical therapy may be helpful to strengthen the pelvic floor. Your doctor may suggest Kegel exercises and may recommend using biofeedback to determine if other exercises would be beneficial.
• Electrical stimulation may strengthen and activate the pelvic floor muscles.

Surgical options:

• Mesh or tissue grafting may be used to strengthen the vaginal wall.
• Stitches may be placed to re-anchor the bladder.
• A bladder sling could be used to pull the bladder back into place.
• If the uterus has also prolapsed, a hysterectomy along with repairs to the pelvic floor may be necessary.

While a gynecologist or urologist may be able to help, find a knowledgeable urogynecologist. These types of physicians specialize in both the gynecological and urological systems and thus may be able to offer the most appropriate treatment. As always, not all options are right for each woman, so weigh your own pros and cons carefully. Seek a second opinion before making any major decisions or scheduling a surgery.

When the tissue between the rectum and the vagina thins, the front wall of the rectum can bulge into the back wall of the vagina creating a rectocele. This type of prolapse is also known as a posterior prolapse and is a very common condition.

The extent of the prolapse can dictate both diagnostic and treatment options. A small prolapse may cause no signs or symptoms and may only be discovered during a routine exam. In more severe cases, the rectum may cause a noticeable bulge in the vagina that leads to uncomfortable symptoms and issues with bowel movements.

Your doctor may perform a pelvic exam while you are lying down and standing up. This can allow him to determine if there is a prolapse and the extent of prolapse. Additionally, you may be asked to undergo a defecography. For this test, an enema with contrast material is given, then X-rays are performed as you have a bowel movement.

For those with no symptoms, expectant management is generally the course of action. Your doctor may monitor you periodically, and you should advise him of any changes in symptoms. Otherwise, no action is taken. Only when symptoms warrant is medical intervention necessary. These symptoms may include difficulty passing stool, the need to split to pass stool, pain with intercourse, and vaginal bleeding.

Non-surgical treatment options can include a high fiber diet, extra hydration, stool softeners, pelvic floor exercises, a pessary, and/or hormone therapy. Surgical options may involve strengthening the vaginal wall and removing any excess tissue. A hysterectomy is usually not necessary unless there are other pelvic organ prolapses that also involve the uterus. Treatment and surgery can be provided by a colorectal surgeon or gynecologist. For non-surgical options, a gastroenterologist may be able to help.

Each woman must weigh her own pros and cons to determine which treatment option is best for her. Seeking a second opinion before making any major decisions or scheduling a surgery. If you have multiple prolapses, consult with a urogynecologist.

Prolapse of the small intestine into the vagina is called an enterocele. This type of prolapse is considered a hernia of the pelvic floor that most often occurs in women who have had a hysterectomy; however, it may occur along with a rectocele even in women with a uterus. There are both surgical and non-surgical treatment options.

The upper walls of the vagina can weaken and separate, allowing the small intestine (or small bowel) to push into the vagina creating the enterocele. Besides a hysterectomy and/or rectocele, other risk factors can include pregnancy and vaginal delivery, natural aging, obesity, and prior pelvic surgery. Issues such as a chronic cough and straining with bowel movements can also be contributing factors.

Diagnosis can generally be made during a pelvic exam. Your doctor may perform the exam while you are lying down and while you are standing up. At times, a defocagraphy (x-rays during bowel movement) may be ordered.

While a minor enterocele may cause no symptoms, a more prominent one can be painful and affect bowel evacuation. Other symptoms can include vaginal bleeding or discharge, painful intercourse, and a feeling of pelvic heaviness. A pulling sensation or lower backache may also occur, but both tend to ease when lying down. You may also experience a bulge inside the vagina.

If the prolapse is minor and causing little or no symptoms, you may be able to follow expectant management. Another non-surgical option could be a pessary. As with most prolapse concerns, vaginal estrogen may be beneficial. Women with any prolapse concern should also avoid constipation, stay hydrated, and perform pelvic floor strengthening exercises. Any contributing health factors should be treated as well.

With surgical options, the goal is to move the bowel back into place, while also closing and strengthening the vaginal walls. Typically, this surgery is completed vaginally. If other prolapses exist, they should be treated concurrently.

Both a gynecologist and urogynecologist can treat an enterocele. Seek a second opinion to help you determine which treatment choice is best for you. Weigh your pros and cons and work with your medical team to develop the right plan for you.

When the pelvic floor weakens and stretches, the uterus can prolapse into the vagina. The severity of the prolapse and associated symptoms can dictate treatment options. In some cases, you may not need any treatment, but for more severe symptoms some type of surgery may be required.

Uterine prolapse, also known as pelvic organ prolapse, is most common in women who have given birth vaginally. Other risk factors include normal aging, loss of estrogen, obesity, a chronic cough, straining, injury, and genetics.

Diagnosis of uterine prolapse can generally be made during a pelvic exam. Your surgeon will classify your prolapse as one of four stages.

• First-degree prolapse: The uterus has only dropped a little. The cervix, the bottom portion of the uterus, may dip into the vagina.
• Second-degree prolapse: The cervix falls farther into the vagina.
• Third-degree prolapse: The cervix may actually protrude outside the body. May be referred to as a complete prolapse.
• Fourth-degree prolapse: The entire uterus has fallen outside the body. May also be referred to as a complete prolapse

Early stage uterine prolapse may be treated with non-surgical methods. These can include exercises to strengthen the pelvic floor, a pessary, estrogen treatment, and a weight loss program. If other health factors are contributing to the prolapse, those should be addressed as well.

For more severe prolapse, surgery may be necessary. The type of surgery may depend on fertility concerns, age, and overall health of the patient, and prolapse severity. In some cases, the surgeon may be able to use nearby ligaments and structures to secure the uterus in a higher position. At other times, a hysterectomy (removal of the uterus) may be recommended.

Not all treatment options are right for all patients. You will need to work with your medical team to determine what is best for you. Women with uterine prolapse should seek a second opinion before making any final surgical decisions. Gynecologic surgeons who specialize in minimally invasive surgery may be able to offer surgical choices that do not involve a large abdominal incision. A urogynecologist may also be able to help.

When the top portion of the vagina falls downward towards the opening of the vagina, a vaginal vault prolapse occurs. This type of prolapse most often occurs in women who have had a hysterectomy. Diagnosis and treatment can depend on the severity of the condition.

Weakened vaginal and pelvic muscles and tissues can be a leading cause of vaginal vault prolapse. Though this type of prolapse occurs most often in women who have had a hysterectomy, a lack of estrogen during menopause can also cause women with a uterus to experience vaginal vault prolapse. This type of prolapse can also occur along with a uterine prolapse and other types of prolapses.

Symptoms of vaginal vault prolapse can include pelvic pressure or heaviness, backache, vaginal bleeding, painful intercourse, and bladder issues. Additionally, there can be a mass or bulge in the vagina. Based on your symptoms, your doctor may be able to diagnose a vaginal vault prolapse through a pelvic exam. Other testing may be needed to determine if other prolapses are occurring concurrently.

The severity of the prolapse and symptoms will determine the treatment plan. Non-surgical options may include a pessary. There are some life style adjustments that can be made as well. These can include pelvic floor exercises, increasing fiber and fluid intake, losing weight, avoiding straining, treating a chronic cough, and using hormones.

Surgical choices will depend on your doctor, your medical facility, and your specific situation. Procedures may be done to attach the vagina to pelvic ligaments or lower part of the spine. A type of mesh or artificial tissue may be used to make the repairs, or grafts of your own tissue may be utilized.

It is very important to share all of your symptoms with your doctor as other prolapses often occur along with a vaginal vault prolapse. This can allow all prolapse concerns to be treated together. Additionally, it is very important to seek more than one opinion before undergoing treatment for vaginal vault prolapse. Because doctors disagree as to which surgery options offer the best outcome with the least risks, seeking multiple opinions can help you determine what is best for you. Before making any final decisions, you may want to speak to both gynecological surgeons who specialize in minimally invasive surgery and urogynecologists.

If your doctor has recommended a hysterectomy for unexplained pelvic pain, you may want to keep exploring your options with a physician. There are many reasons for unexplained pelvic pain with endometriosis and interstitial cystitis (IC) at the top of the list. Neither of those conditions are cured with a hysterectomy.

A hysterectomy will stop a woman from menstruating. This also stops menstrual cramps. Removing the uterus, however, may have no effect on conditions that exist outside the uterus including endometriosis and interstitial cystitis. If the endometriosis implants are responsible for symptoms (pain with intercourse, diarrhea, painful bowel movements, painful or frequent urination) and they are not removed along with the uterus, the symptoms will not change. If IC is responsible for your symptoms (urinary frequency, urgency, and severe lower abdominal or perineal pain), the condition needs treated specifically to try to alleviate the inflammation and allow the mast cells in the bladder to heal. Trauma can increase symptoms so a hysterectomy could intensify your symptoms.

Similarly, removing the ovaries and leaving endometriosis behind is not likely to do anything but throw the patient into menopause, possibly creating a whole new set of problems. Hormonal issues can also negatively impact IC.

When a hysterectomy is performed for endometriosis, removing the endometriosis implants along with the uterus can give the patient the best possible chance for relieving her symptoms. Preserving the ovaries if possible, particularly in the younger patients is recommended.

There are also many other non-gynecologic problems that could cause pelvic pain.

• Addiction or substance abuse problem
• Anxiety
• Arthritis
• Chronic appendicitis
• Chronic interstitial cystitis (chronic bladder infection)
• Depression
• Lumbar disk disease
• Diverticulitis (intestinal inflammation)
• Fibromyalgia
• Hernia
• Inflammatory bowel disease
• Irritable bowel syndrome
• Physical or sexual abuse
• Scoliosis and posture-related problems

It is important to explore the cause of your pelvic pain so that you don’t have an unnecessary hysterectomy.