Severe menstrual cramps in a young lady

Today it looks like more and more younger women are suffering from endometriosis. It is known to be a disease of affluance and maybe a reflection of our societies increasing affluance and higher living standards in Singapore. Endometriosis some 10 years ago was commoner in those 40 and above but it seems that I am seeing more women in their 20's with this condition. Endometriosis or chocolate/ blood cysts can cause a great deal of damage to a woman's reproductive organs as it is almost as destructive as a cancer. Although not life threatening, it causes the pelvic structures to become `glued' together and obstructs the development and release of eggs and blocks the passage where the egg and sperm meet. I recently encountered a young lady of 29 years with this condition who was diagnosed in 2008 to have an ovarian endometriotic cyst and was supposedly cleared through a laparoscope by another gynaecologist. However when I saw her, both her ovaries were enlarged with endometriotic cysts measuring 3 cms, they were also `glued' to the back of the womb and the pelvic wall. She was having difficulty with conceiving. I did an operation to free all her reproductive structures and removed the cysts in both ovaries. We are now waiting for 3 months before she will try for a pregnancy

Unusual symptom of a tilted womb

I had a patient consult me with the problem of faecal incontinence. She was unable to control her bowel movements and whenever she had the urge to go to the toilet she would leak faeces before she could reach the toilet. Faecal incontinence can occur in those who have had previous normal deliveries and have had tears of the anal sphincter as a result of the delivery. Sometimes a difficult assisted delivery can cause this. However this patient had two previous deliveries by caesarean section some 10 years ago. The only significant finding was a tilted or retroverted but slightly prolapsed womb on pelvic ultrasound scan. Now a retroverted uterus is common and is present in about 20% of women. It is known to cause infertility, dyspareunia or painful intercourse and backache, however it has not been known to cause faecal incontinence. The patient was counselled and was advised that an operation to correct the retroverted uterus may not help her symptoms. However, the patient decided to go ahead with the operation. I have followed the patient up for 6 months after the operation and to my surprise she is free of this debilitating and socially embarrasing condition of faecal incontinence.

Dermoid cyst + Polycystic Ovaries

Today I saw a young lady with intermenstrual bleeding and long menstrual cycles. She was obviously distressed about her symptoms as she had been told by 3 gynaecologists 3 different diagnoses. She was about to get married and was keen on starting a family. The diagnosis of polycyctic ovaries given by one gynaecologist made her very anxious as she knew this was associated with subfertility.
An ultrasound scan of her pelvis showed a large ovarian cyst with solid areas attached to a polycyctic ovary Her other ovary was also enlarged but with multiple small cysts. I immediately did an ovarian cancer screen for and a hormone profile. As she was in her 20's it was unlukely that she had a cancer of the ovary although I have seen a few cases of early cancer of the ovary in women in their late 20's. The most likely diagnosis was of a dermoid cyst, and this diagnosis had again been missed by the other gynaecologists.
A dermid cyst is a cyst that is present from an early age and contains all the embryonic tissues such as hair, teeth, bone, cartilage, sebum etc. They can sometimes grow quite big and twist or rupture. It is advisable in such cases to remove them if they have grown to a certain size. very often they are bilateral and at the time of operation the other ovary must be examined carefully for any small dermoid cyst that can be easily missed.

Breast cysts to cancer

I recently saw a patient who had been followed up for many years for breast cysts. they had been reported as non cancerous. The patient however diligently followed my instructions to have her breast scans every six months. After 10 years, the breast scan showed that there were some slight changes in the shape of her cysts. All scans prior to that had beeen normal. I did a biopsy of her beast cyst and it returned as an early cancer of the breast. The take home message from this is that always be consistant in regular checkups even though they may have been normal for a long period of time. An early breast cancer detected has a good chance of  100% cure if treated early appropriately.

Cancer of cervix Stage III

I recently had a young patient of 38 years who had been to see a doctor in Batam because she had bleeding after sexual intercourse for several months. The doctor did an examination, some tests and told her she was alright. Her husband was not convinced and brought her to see me. After a speculum examination it was almost certain that this young lady had a cancer of the cervix. An ultrasound scan showed a bulky mass in the cervix extending up to the uterus. I immediately oredered a CT scan and IVU to determine if there was spread to organs outside her cervix.I also did an examination under anaesthesia and a biopsy to confirm the cancer. It was a stage III cancer. Now this lady has a prognosis of 20-30% survival even after radiotherapy and chemotherapy.
Cancer of the cervix is a preventable condition. With the yearly PAP smears that most women have there is no reason why someone should end up with a stage III cancer. Cancer of the cervix used to be the number 2 cancer in women but no longer in todays context. What did this patient do wrong? Firstly she did not go for yearly check-ups, she did not do an HPV-DNA screen ( one cannot get cervical cancer without first contracting HPV a sexually transmitted virus) and she delayed seeing a doctor. Even though the recommendation for PAP smears is once in 2 years if you have a normal smear, it is prudent to do them yearly as a lot can happen in 2 years. Also an HPV screen which is now available can set our mind at ease if it is negative or make us more vigilant if it is positive. It is indeed a waste to see a young woman in this day with a cervical cancer stage III when this could have been prevented. Indeed, Singaporeans are now vaccinating themselves against  HPV.

Why IVF(test tube baby) should not be the first option

As more Singaporeans delay having children, and the older married woman comes wanting the fastest way to get pregnant, many nowadays come to consult me with the idea that invitro fertilisation is the first line of treatment. I have to counsell them of course that IVF is actually the last resort! and should be so. Many in the course of the investigations and stepwise treatments will get pregnant before reaching the stage of IVF. Firstly, IVF is expensive and the results are not guaranteed as some women think. The results of IVF actually vary from 20-30% per cycle being lower the older the patient. And here's the main reason why women should not resort to IVF first, the incidence of abnormalities in offspring is significantly higher especially with ICSI (intracytoplasmic innoculation) and no one knows the real reason why. It may be related to increased risk of chromosome abnormalities or defects resulting from mechanical manipulation. Miscarriages are therefore significantly higher and this can be very traumatic psychologically.
http://www.lifesitenews.com/news/archive/ldn/2009/mar/09032310
http://www.lifesitenews.com/news/archive/ldn/2003/sep/03092206
http://www.lifesitenews.com/news/archive/ldn/2010/jun/10061406
http://www.lifesitenews.com/news/archive/ldn/2010/mar/10030107

Fibroids and Pregnancy

With later marriages come later pregnancies. It is not uncommon to see women having their first child in their mid to late thirties today. I had a patient come for a checkup wanting to start her family and an ultrasound scan of her pelvis showed a fairly large fibroid. The previous gynaecologist had told her that it was alright to get pregnant with the fibroid in her uterus so she thought nothing of it. She did not have any symptoms. Fibroids in pregnancy are more and more common nowadays. Whether it affects the pregnancy will depend alot on the position of the fibroid. If it is near the cavity, it may cause a miscarriage, cause the baby to lie in the wrong position or block the passage of the baby at birth. The pregnany is therefore more risky for the baby and mother. The fibroid may grow rapidly due to the sudden surge of pregnancy hormones and this may cause severe pain due to 'degeneration' in the fibroid. The pain would be multiplied if there are several fibroids. Caesarean sections would be more dangerous too because of excessive bleeding or having to cut near the fibroid to get the baby out. The choice for the patient was therefore whether to take out the fibroid first and then try to get pregnant or to get pregnant knowing all the possible problems that it brings. An operation to remove the fibroid meant a wait of a year after before she was able to try for a pregnancy. As she was already in her late thirties, she opted to get pregnant with the fibroid in the uterus.

Mammogram or Mammogram+ Ultrasound scan or MRI Breasts

Everyone above 40 would probably have had at least one one mammogram. And everyone without fail will say that it is painful! Nevetheless it has to be done as only about 8% breast cancers are detectable by manual palpation. The diagnostic accuracy can be improved significantly by adding on an ultrasound scan of the breast. This also helps with picking up breast cysts which would be missed by conventional mammogram alone. In Singapore, polyclinics often will just offer a mammogram. This in my view is inadequate as it will miss a number of breast cancers. Besides, the cost of adding on an ultrasound scan is not much. In those with dense breasts, those who are averse to the pain of mammogram, and those who don't mind the extra cost, an MRI of the breast is an excellent alternative and in fact increases the diagnostic accuracy even more. In time to come perhaps all women will be opting for MRI of their breasts instead of a mammogram.

Why you should take HRT

Everyone knows from the media and unfortunately, faulty WHI study on the risks of HRT. The trouble is that the study was flawed in that it was done on an old age group of women who had started HRT after 60 years. Most studies since then have showed that firstly the lefetime risk of breast cancer is less than 1% which is miniscule. The risk of heart problems is also not increased as previously thought but is in fact decreased with HRT.

There are alot of benefits of HRT and women today are shying away from using it and suffering because of the 2002 WHI study and the subsequent sensationalism in the press. HRT will stop any hot flushes, depression, anxiety, prevent disc degeneration and therefore shortening of the spine and height, prevent osteoporosis or softening of the bones and therefore fractures, prevent heart problems such as heart attacks, strokes, prevent loss of libido, prevent dryness of the vagina and painful intercourse, prevent infections of the vagina, prevent loss of skin elasticity as with menopause there is a loss of collagen and that causes the skin to sag, general well being and mood elevation. So you can see that there are alot of benefits, and with the availability of bioidentical hormones now there is no reason why women should shy away from hormones. Indeed I see an increasing number of knowledgeable women in my clinic who are now experiencing the benefits of hormones.

Short menstrual cycles

This would be defined as cycles of less than 26 days. In most cases, there is a deficiency of the female hormone oestrogen. Droopy breasts, depression, irritability in the second half of the cycle will indicate that this is the most likely cause. However if the breasts are painful and swollen in the second half of the cycle then the short cycles are related to a progesterone deficiciency.
A blood test should be done to determine the cause and to make sure that there are no other deficiciencies such as thyroid hormone which will cause the ovaries to malfunction.Treatment would be with bioidentical hormones, the timing and dosage should be adjusted according to the problem.

Hormonal treatment of endometriosis

In endometriosis, typically the mucous membrane which is present on the womb lining develops in unexpected places such as the ovaries, colon or outer surface of the womb. It is related to a deficiency of the female hormone progesterone which is responsible for keeping the endometrial growth at normal levels. As a result there is excessive growth of the womb lining and allows growth in those areas described.

Thyroid and cortisol deficiencies may also cause progesterone deficiency, and will need to be corrected at the same time. Treatment is with progesterone ( the type of progesterone used depends on the severity of the endometriosis) Magnesium deficiency should also be corrected and this will allow relaxation of the womb muscles. Avoid all milk products, sugar and food allergens which may irritate the colon and allow growth of endometriosis. In many cases, treatment with progesterones may be insufficient and strong drugs such as danazol, lucrin have to be used.

Endometriosis starts at a young age and very often the symptoms of painful periods are passed off as just part of growing up, some will just bear with the pain for many years thinking that it is normal and will disappear after giving birth. Eventually many of my patients present in their late 30s with persistent pain and or infertility and I will find extensive and severe endometriosis with big ovarian cysts and damage to the surrounding organs. They inevitably need surgery followed by medical treatment to prevent a recurrence. The take home message would be to have a gynaecological checkup as early as possible especially if painful periods are present. Regular checkups will ensure that the condition is picked up at an early stage and treated appropriately.