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.