Ovarian Cyst

Ovarian cysts are so common that I see almost 3-5/ week in my practice. Very often they have little or no symptoms and are found routinely at the yearly gynaecological check-up. The most common are the functional cysts which are related to the menstrual cycle. These cysts are due to an imbalance of the bodies hormones and they will often correct themselves or can be treated simply by balancing the hormones. Pathological cysts on the other hand are abnormal and will not disappear with medical treatment. They will need surgery as they are sometimes cancerous. The cysts may be filled with fluid or blood. Some are present from birth and grow to a size that can eventually be detected by ultrasound scanning. They are filled with hair, teeth, bone and sebum!. Symptoms may include painful periods, heavy or irregular periods, painful sexual intercourse and abdominal bloatedness and pain.

Ultrasound scan, blood hormonal tests and ovarian cancer screens are some of the tests done before deciding on whether surgery is needed. Unless a cancer is suspected, most ovarian cysts can be removed by key hole surgery.

Fibrocystic disease of the breasts

This very common condition is characterised by painful lumps in the breast. There are both solid and cystic lesions seen when an ultrasound scan is performed. They are usually multiple in nature. Typically the patient will experience swollen and painful breasts before and sometimes during her period. This condition should be distinguished from a fibroadenoma which is a single solid lump. Whatever the nature of the lesion it is always advisable to have a biopsy ( surgical removal) to exclude a cancer even though the mammogram or ultrasound scan shows that it is likely to be benign. I had a patient recently who had a 7 cm lump in her breast. She did not go to see a doctor out of fear and had left the lump to fester for many years. The scan showed that it was likely to be benign but at removal there was a focus of cancer. Breast cancer is the most common cancer in women today, and every woman should have a mammogram at least once in 2 years after 40 years of age.

Having confirmed that the fibrocystic disease is of a benign nature, a hormone profile done will often show an oestrogen predominance and low progesterone ( hormone levels). Prevention of recurrence and control of the disease is possible by balancing the hormone levels. One should also reduce salt intake, and consume less soy products. Evening primrose oil will also help reduce the effect of oestrogen on the breasts.

Breast and Ovarian Cancer link

You may wonder why your gynaecologists asks you if you have a family history of breast or ovarian cancer during your routine check-up. There is in fact a hereditary element in women with certain breast cancers. These women will carry an abnormal BRCA1 or BRCA2 gene. This is more likely so if she develops breast cancer at a young age. The abnormal gene can be tested for if there is a history of breast or ovarian cancer in the family. If the defective gene is found there is a 60% chance of developing breast cancer and a 55% chance of ovarian cancer. Some women will, in such a case,  opt for elective removal of their breasts and ovaries, as in my patient. She did the test as there was a strong family history of breast cancer. The test came back positive test for BRCA1 and she decided that she didnt want to take the risk and so had a bilateral mastectomy. I then performed a video laparoscopic (key-hole) removal of both her ovaries. Of course this will bring about a menopausal state. However I discussed this with her beforehand and she decided that she would rather take HRT for life then risk an ovarian cancer. Women who develop breast cancer should do the BRCA1 & 2 gene and if positive should consider having their ovaries removed as well.

Tired and Moody

The other day I had a patient who presented to me with vague symptoms of mental tiredness, lack of energy, mood swings and increasing weight gain. She was of course perimenopausal. So the obvious cause and treatment would be with some form of HRT. So I started her on oestrogen and progesterone. The symptoms didnt get better and she came back pleading with me to help her do something. She was already on Prozac for depression. Of course it would have been easy to have dismissed her symptoms as something cerebral. However, I gave it a shot and gave her some chelated magnesium, acetyl carnitine. Low and behold, the effect was instantaneous, she was feeling better the next day and she is ever greatful to me for helping her. Who would have guessed that it was just a deficiency in minerals!

HRT - Synthetic or Bioidentical

When women reach their 40's,  hormone levels often go out of balance or decrease to the extent that it causes symptoms. Sometimes these may be very non-specific eg loss of energy, difficulty with sleeping etc. When hormone levels have dropped to significant levels ie nearing menopause, the symptoms of flushes, irritability, loss of libido, dryness in the vagina, sagging skin, become more pronounced. The knowledgeable ones will seek treatment early. The problem is that mainstream gynaecologists will be loath to prescibe hormones too early, many women will refuse hormones because of fear of braest cancer, so women suffer and the loss of the bodies natural hormones leads eventually to bone loss, osteoporosis, heart problems, depression as well as non health related problems such as marriage and family problems, problems at work.

The initial studies that showed an increase risk of breast cancer were with synthetic hormones and therefore could be criticised. Bio-identical hormones (BHRT) use hormones that are identical to the bodies natural hormones whereas synthetic hormones (HRT) were similar in chemical structure and in some cases derived from urine. BHRT is usually prescribed in the form of creams. The advantages of BHRT are that they then bypass the liver and are therefore not converted by the liver into other substances. The doses used are also much lower and tailored to the the individual so that hormone levels are raised and maintained usually to that of a woman in her 30s/ 40s. The hormones are not raised to dangerously high levels. BHRT can even be started in women well before their own hormone levels start falling, thereby maintaining their youth.

Multiple fibroids- myomectomy vs hysterectomy

Almost 50% of women who reach 40 years of age will grow fibroids in their uterus. Symptoms that require treatment include heavy or irregular bleeding, urinary symptoms such as frequency or recurrent urinary tract infections, abdominal pain or when the fibroids grow rapidly. Fibroids are fibrous growths which start off as small seedlings and can grow to the size of a football. They may be multiple or singular. My stamina, patiience and eyesight were tested the other day when I had to remove over 30 fibroids from a patients uterus!.( that is not my record!) I say that because it takes time to find and remove all the small seedling fibroids and surgery can last a long time as one looks for needles in a haystack! It is however rewarding because not only does it relieve the patient's symptoms but it also saves her from having a drastic and major operation such as a hysterectomy. If possible this should be the treatment of choice in my opinion, especially if the patient has a healthy sexual life and is not near her menopause. Some gynaecologists may disagree, and recommend hysterectomy as the first line. A hormone profile should also be done and any imbalance corrected to reduce the chances of a recurrence.

                                                         CT scan showing multiple fibroids

Atrophic Vaginitis during menopause

This common problem arises during the peri and menopause period. It happens because of a decrease in the female hormone oestrogen. As a result changes in the lining of the vagina take place causing it to be thinner, more susceptible to infection and inflammation. If you are starting to feel itch, discomfort, dryness and pain with intercourse, more discharge then usual then you probably have this condition and should seek help from your gynaecologist. Of course not every peri or menopausal woman will have it, but there is no need to suffer the discomfort as treatment is available. In a sense treatment should be sought as the vagina will slowly contract in size and the lining of the vagina will eventually stick together and make it difficult to view the neck of the womb necessary for doing a PAP smear. An early cancer of the cervix can therefore go undetected. 

Treatment is with creams or pessaries inserted in the vagina. The oestrogen pessaries are inserted nightly for 2 weeks to obtain a therapeutic effect and then maintained with 2 weekly insertions. The effect of the oestrogens is local and only a small amount is absorbed into the blood stream, making it safe to use for prolonged periods. Oestrogens taken orally are mostly ineffective for this condition.

Obesity associated with Polycystic Ovary Syndrome (PCOS) and diet

Diet is important in a patient with PCOS to help control the condition. Obsesity in PCOS is very common due to insulin resistance ie the levels of insulin in the body are high. This happens because there is a defect in getting the blood sugar into the cells so the pancreas secretes more and more insulin. It has been shown that just reducing weight by 5% can help improve the condition. Periods go back to being regular and insulin levels decrease, skin improves. The problem is that it is difficult to lose weight in PCOS. The normal diet of low fat high carbohydrate diets dont work because the refined carbohydrates are quickly turned to sugar in the blood, and this in turn raises the insulin level even higher. The ideal would be a low carbohydrate high protein diet, combined with aerobic excercises. Some carbohydrate should be consumed to prevent ketosis. Complex carbohydrates such as whole meal bread and brown rice should be taken in small amounts. Low glycaemic foods should be part of the diet so as not to allow spikes of blood sugar. So diet and excercise are the first line of treatment for PCOS especially when associated with obesity.

Endometrial ablation as an alternative to hysterectomy for heavy periods

When endometrial ablation was introduced in the 1980's it was all the rage, and I was one of the few gynaecologists to start using this surgical treatment in Singapore for the treatment of heavy periods and fibroids in the endometrial cavity of the womb. Endometrial ablation involves in simple terms removing and ablating the lining of the the womb similar in the way an enlarged prostate is removed surgically in a man. It involves introducing an intrument through the cervix and stripping the lining of the endometrium and then with the aid of electrocautery ablating whatever remnant of the lining. It is a minimal invasive procedure with the patient going back the same day. For those patients who desired keeping their womb and were averse to surgical hysterectomy, this offered a good surgical alternative. However over the last 20 years of use, studies have shown that in about 20%, the heavy periods will recur as the endometrium has a tendency to grow back after several years. So most will go on to have repeated ablations and some end with hysterectomies. The types of ablation have evolved to include freezing, high thermal, and microwaving. Certainly endometrial ablation has a place in intractable menorrhagia (heavy periods) but not for everyone.

Endometriosis and Adenomyosis

I recently operated on a 28 year lady with both endometriosis stage III and with significant adenomyosis. Although endometriosis is a rather common condition in women especially those in there 30s and 40s who have few or no children, this was unusual in that here was a relatively young lady, getting married, in the best reproductive years of her life with extensive endometriosis and adenomyosis. Endometriosis is a generalised pelvic condition in which there are blood cysts scattered throughout the pelvis but mainly in the folds between the womb and the bladder in front and the rectum and intestines behind. There is also a predeliction for the ovaries as well. In stage III endometriosis, there are large blood cysts involving both ovaries and extensive adhesions of the surrounding structures. The disease acts almost like a cancer attaching and invading surrounding tissue although it is not malignant. It is simply distructive to the structures and can significantly affect her fertility. She presented with heavy irregular and painful periods. Very often there may be no symptoms other then infertility and found during investigation for such. In addition she had adenomyosis. This is blood cyst mixed together with a fibroid and is present and invades the muscle of the womb. Pain during the period comes from the bleeding from all these blood cysts. If the cysts are large they may even rupture during the period.

In her case I obviously had to be as conservative as possible. She was offered the alternatives of medication in the form of danazol for 9 months or a gnrh agonist lucrin. Both would induce a semi-menopausal state and allow the shrinkage of the cysts. This would however not be ideal as it would be impossible to shrink away the disease and cysts totally. She was therefore offered surgery as the better alternative followed by medication as the better choice.

Such extensive disease is unusual and requires careful considerate surgery to restore her fertility. Endometriosis and adenomyosis is thought to be an immune disorder and is related to backflow of menses through the fallopian tubes allowing the cells to implant on the pelvic structures. It should be suspected especially if periods get increasingly painful. Diagnosis early in stage I would prevent further progression with medication or use of laparoscopic laser surgery (key hole). Regular gynaecological checkups with ultrasound scanning from an early age is the key.

Uterine Prolapse

A few days ago, I performed a vaginal hysterectomy on a patient with uterine prolapse. She had a 3rd degree uterine prolapse with the entire uterus hanging out of the vagina!. It is actually quite unusual to see these cases nowadays with women having only a couple of children. In the olden days when women tended to have large families this was very much more common, and when I was working in the UK, a vaginal hysterectomy for prolapse was one of the most common operations performed. These women would come with the complaint of pressure below, a lump appearing or tell the doctor that she was turning into a man!.

Prolapse is a gradual process and results from damage to the supporting tissues at childbirth. As a woman ages especially in her 40s and 50s, there is increased laxity of the collagen due to decreasing female hormones, oestrogen. The prolapse then worsens. 1st degree and 2nd degree prolapse are less severe, but 3rd degree prolapse or procidentia can result in damage to the kidneys due to kinking of the ureters between the kidneys and the bladder, ulcers and cancerous change of the cervix due to the constant rubbing on underwear. My patient did indeed have swollen kidneys before surgery but an xray after the hysterectomy showed that the kidneys had reverted back to normal size. A 3rd degree prolapse and hysterectomy can be prevented if prolapse is detected in the earlier stages and supportive surgery performed. A sensation of heaviness, constipation, difficulty with urination or leakage of urine on excercise or coughing may indicate uterine prolapse.

Osteoporosis and Calcium

It is a common belief that taking calcium and excercising is all that is needed to prevent osteoporosis (softening of the bones) in the menopause. Taking calcium is important but all the more important in prevention is ensuring that  calcium intake is adequate from as young as the teenage years. Studies have shown however that overdosing with calcium does not prevent osteoporosis. Those who have low calcium intake should go with about 600-700mg/day to avoid deficiency. Taking more is not better. Osteoporosis in menopause  is due in part to a lack of the female hormone oestrogen. Without oestrogen the calcium has difficulty in being absorbed into the matrix of the bone and is simply excreted in the urine. Thus, prevention would involve ensuring an adequate calcium intake from diet and supplements, excercise and adequate oestrogen in the body.

Oestrogen levels start decreasing from the early 40's and if combined with an inadequate calcium rich diet and lack of excercise, could lead to the onset of osteoporosis even better full menopause has been reached.
It is therefore important to start calcium supplements early as possible, excercise and see your gynaecologist who will check your hormone levels.
http://www.latimes.com/health/boostershots/la-heb-calcium-20110526,0,408286.story?track=rss

Pelvic Infection

Why are intrauterine devices (IUD) and contracting a sexually transmitted disorder (STD)  dangerous in those who haven't had children? The risk of pelvic infection and infertility due to damage to the fallopian tubes is high. The incidence of  STD's has been steadily rising with the incidence of chlamydia infection as high as 1:10 women in some countries. The trouble is chlamydial and gonococcal infections can have relatively few symptoms and in some none at all. The bacteria however has a propensity to climb up the genital tract to the fallopian tubes causing an inflammatory reaction and subesquent blockage.

I recently had to operate on a lady with vaque abdominal discomfort and little else, but with large masses on pelvic ultrasound scan. At operation the masses as suspected were tubo-ovarian abscesses with structural inflammation, swelling and adhesions to surrounding organs. The damage was too great to save the fallopian tubes, and the condition could well have been life threatening if not for early intervention. The same infection could well have been caused by common bacterial infection resulting from inserting an IUD. Which is why an IUD, although a convenient form of contraception, should never be inserted in a women who has never had children or are planning for more.

Avoidance would be the best, but if not, early detection through vigilance and early treatment with antibiotics would greatly reduce the need for surgical intervention and the possibility of long term damage and perhaps heartache.

Newer HPV test

It is common knowledge that cervical cancer is related to HPV (human papilloma virus ) infection. There are many strains of HPV but 98% cervical cancer is due to HPV strains 16, 18 . HPV-DNA testing has been available in Singapore in the last 2 years and forms part of the testing that is done during the annual PAP smear. Although not always offered, it is a test which is advisable as it gives an indication of whether you are at high risk of cervical cancer even though your PAP smear may have been normal.

It is now possible to detect whether infection is due to the two main strains ie 16 and 18. A positive test means a 4x higher risk of cervical cancer. A positive test with a normal PAP smear should then be investigated with a colposcope (microscopic examination). Colposcopic examination and perhaps a biopsy may be necessary. A normal PAP with HPV positive of other strains need not be examined with colposcopy but observed. The HPV may in time be removed from the body by the bodies immune system and revert to HPV negative.

Ovarian Cancer screening

Even though ovarian cancer is the second most common gynaecological cancer it is often forgotten or overlooked. Screening is not often done and a routine yearly PAP smear doesn't pick up ovarian cancer unless and ultrasound scan of the pelvis is done at the same time. Ovarian cancer is the most dangerous of all the female cancers as it does not present with any symptoms until the cancer is in the advanced stage. The good thing is that if discovered early ie stage I, the cure rate is extremely high.

The best way to pick up an ovarian cancer is to have a pelvic scan at the time of your regular PAP smear. An ovarian cyst with or without features of ovarian cancer will be seen. The next step is to determine whether it is likely that this ovarian cyst is cancerous by doing a blood test called the oviplex screen. Previously, a single cancer marker, CA 125 was used but this has shown to have an accuracy rate of only 60+%. The oviplex screen is recently available and this combines the CA 125 with other blood markers giving an accuracy of over 90%.

Urgency incontinence ( overactive bladder )

This is a common problem in women and should be distinguished from stress incontinence. The need to go several times a day, and the feeling of having to go again almost immediately after emptying the bladder, getting up at night to go, or being incontinent if not able to get to the toilet in time, indicates urge incontinence . The cause is often due to a hyperactivity of the nerves on the back of the bladder which are responsible for the sensation of fullness of the bladder. Whereas stress incontinence is a condition when increased pelvic pressure such as coughing, sneezing, excercising brings about a leakage of urine.

Once your gyne has excluded a urinary tract infection, he could then diagnose the condition through urodynamic studies or alternatively give you a trial dose of a drug for the treatment of urge incintinence and see if there is improvement. Initially, 'bladder training' may help. Getting you to delay voiding urine and gradually increasing the interval of time between voiding over a period of time will stretch the bladder and enable you to hold more urine. The drug of choice is detrustol ( tolterodine tartrate ) given as a single long acting dose.

Recently studies have been shown that botox injected into the bladder wall appears to help with this condition. The use of botox however is still experimental and at this point of time should be used only in cases of intractable urge incontinence. The effect of botox is also temporary and lasts for a few months.
http://www.obgmanagement.com/article_pages.asp?AID=4668

Are oral contraceptives safe?

In Singapore fewer women use oral contraceptives than in western countries. They are usually concerned about putting on weight and acne changes. Although the newer oral contraceptives (OC) seems to address this problem, new studies  show that the older generation of OCs may be safer than the newer generation ones in terms of more serious side effects!. The older generation OCs would be microgynon 30 which contains levonorgestrol while the newer third generation OCs such as mercilon and yasmin contain desogestrol and drospienone respectively as the progesterone component of the OCs. Recent studies show that the risk of non fatal thromboembolism ( blood clots in the legs..sometimes known as the 'economy class syndrome' ) is double that of the older generation OCs! The overall risk of thromboembolism however is very low.

In the light of these studies, it may be prudent to take the older generation OCs as first line if this is the choice of contraception.
http://www.bmj.com/content/342/bmj.d2151

http://www.bmj.com/content/342/bmj.d2139

Heavy periods

Heavy periods ( menorrhagia ) is a common problem which many women tolerate until they either become anaemic or so anxious as it becomes a social problem. I remember a patient who very often when she attended  functions or events would have to excuse herself because she  had to go to the toilet until one day she collapsed in a cinema toilet and had to be helped to hospital.

Because of the adverse publicity of hormones in its treatment, many women either simply take iron tablets and hope for the best. Your gynaecologist may have suggested surgical options such as stripping the uterine lining or a hysterectomy, and this may be the best option eventually for intractable menorrhagia. However there is a drug that is not often used by gynaecologists but does have good results in controlling menorrhagia from a recent double blind study. Tranexamic acid ( Cyklokapron ) given during periods dramatically reduces the heavy flow. Menorrhagia may be due to an excess of plasminogen in the body which prevents clotting. Tranexamic acid prevents the effects of plasminogen on the clotting mechanism. Of course your gynaecologist will first have to rule out other causes for the menorrhagia such as fibroids, endometriosis and cancer which will require surgery. So this drug would be a useful alternative to those who do not want hormonal or surgical treatment where the menorrhagia is not due to any pathological growth.

Polycystic Ovaries ( PCO )

You may have been trying to get pregnant without success, and noticed that your periods are often delayed, you are putting on weight, or you have persistent acne. This may be due to a condition called polycystic ovary syndrome ( PCO ). Or your gynaecologist may have told you that you have PCO. Do you really have PCO?. The diagnosis is made on the finding of multiple small cysts on the outer portion of both ovaries on ultrasound scan (>8 cysts) and a hormone profile which shows an imbalance in two hormones (LH:FSH of >2:1). There may also be a raised male hormone, testosterone.

Nobody knows why this condition comes about but it is extremely common. It can occur from a young age or later years, it may be temporary or longstanding. If temporary, weight gain is usually not an issue and the irregular periods spontaneously resolve. If longstanding, the condition may be mild or become more severe with increasing weight gain, excessive hair growth, periods even just once or twice a year. There is also a tendency for these women to develop diabetes in later life.

Treatment will depend on the severity of the symptoms and whether pregnancy is desired. If wanting to get pregnant, the options include fertility tabs, injections, or surgery which involves drilling and clearing the cysts from the ovaries.There is a feedback mechanism to the part of the brain which controls the hormones and it appears that this procedure causes the a 'shake-up' resulting in a re-regulation of the hormones. The procedure is done through key-holes as a day procedure.  Medical treatment to lower the male hormone, and a drug known as metformin appears to help. Losing weight also appears to have a great effect in treating this condition. Unfortunately, it is difficult to lose weight with this condition!

 The miscarriage rate is much higher if pregnancy is achieved with PCO. Nobody knows the reason but is thought to be related to the high hormone levels. The risks are even higher if conception with metformin is achieved.

                                                 Ultrasound scan showing cysts in ovary

HRT and Menopause

Almost everyone is aware that HRT has been linked to cancer of the breast. This came out of the WHI study in UK which showed that those women who took HRT for more than 5 years were at greater risk from breast cancer, cardiovascular problems and stroke. There was however a flaw in the study in that it comprised predominantly women in the older age group who of course would be at greater risk of getting breast cancer in view of their age. Later, it was found that those who had combined oestrogens and progesterones were at greater risk than those who only took oestrogen. To make matters even more confusing, a new study now shows that if oestrogen is given to women in the 50's, it reduces the breast cancer risk!. It is no wonder that not only is the public confused but so are many gynaecologists!. Apparently the oestrogen gobbles up any potential breast cancer cells.

So what are we to deduce from all this. The most prudent would be to recommend HRT for no longer than 5 years, and to use the safest oestrogens and if progesterone is needed, micronised progesterones. Regular mammograms should be routine in those on HRT, and maintaining a healthy lifestyle free of smoking and drinking and excercising regularly

Other alternatives such as black cohosh, isoflavones, dong qui, etc however have not been shown to have a significantly greater effect than conventional HRT in improving symptoms. They all act on oestrogen receptors and therefore have the same risks as HRT of breast cancer.

Premature Menopause

As the title means, menopause before the time is due. This is usually taken as before 40 years. Not common but the incidence is rising now at 1:100. I had a young lady of 20+ the other day who stopped having periods suddenly for several months. She was studying in university and was back on holiday. Hormone tests showed that the hormones related to menopause were raised and her female hormones were low. I was hesitant to diagnose PRM and repeated the tests which came back the same. Very trepidly I broke the news to her mother. PRM is usually permanent but in about 5% of cases, a reversal of ovarian activity spontaneously is possible. That was the good news. The not so good news was that if permanent, leads to softening of bones, heart problems and depression and of cause the most devastating for a girl at that age, infertility.

PRM should be treated with hormone replacement as the advantages far outweigh the risks. She was also asked to take vitamin D and calcium supplements, excercise, and avoid smoking and drinking as a long term measure to prevent bone loss.

A little biology on ovarian activity. Every woman is born with thousands of immature eggs. From the time puberty starts, there will be a crop of eggs each month that grow and one egg will be released from either ovary. Therefore every month of a woman's life, there will be a depletion of eggs. When a woman reaches her 30s and 40s, there will be a gradual reduction of ovarian activity resulting in a fall in oestrogen, the female hormone. Menopause begins when ovarian activity ceases. There may be a long period termed the perimenopausal phase when the symptoms of menopause viz. hot flushes, irritability, depression appear. These may disappear or persist depending on the individual. The average age for menopause is 47-55 years.

A later menopause is not necessarily a good thing. It is related to a higher incidence of breast cancer and uterine cancer due to the effects of oestrogen.