Patient information

NovaSure Endometral Ablation

What is NovaSure Endometrial Ablation?

It is an operation in which the lining of the womb is treated (burned) by a type of energy known as Radiofrequency Energy.

Why is this type of surgery used?

It is used for women with heavy periods (Menorrhagia) to reduce menstrual bleeding.

How is it done?

It can be done either as an office procedure in the outpatient department under local anaesthetic or as a day case under full anaesthetic. Your doctor will insert a slender wand and extend a triangular mesh into the uterus. A measured amount of energy will be delivered through this mesh for 90 seconds. The device is then removed from the uterus.

How effective is it?

In 90% of women, menstrual bleeding is dramatically reduced or stopped.

Are there any alternatives?

  • 1. The Mirena device (hormonal coil) is an alternative.
  • 2. Not all women are suitable for NovaSure. If you have a large fibroid inside the womb, then removal of this fibroid vaginally can be done using a hysteroscope. However, if you have a small fibroid, NovaSure ablation still can be done.
  • 3. Hysterectomy: can be considered if you are not suitable for NovaSure or if it has failed.
  • 4. Medical treatment: such as Mefenamic acid, Tranexamic acid tablets or Progesterone tablets (Northisterone). However, in most women, this has usually been tried before considering NovaSure.

Can I become pregnant after receiving NovaSure treatment?

It is usually advised to consider this procedure for women who have completed their family or are not planning pregnancy in the future. Therefore we advise any method of permanent, reliable contraception.

Further information: www.novasure.com

Anterior and Posterior repair

Surgical procedure
(Cystocele and Rectocele)

A cystocele occurs when the bladder and/or urethra prolapses or ‘drops’ into the front wall of the vagina.

A urethrocele is when the urethra only is prolapsing.

Repair involves removing a piece of vaginal skin, then stitching the bladder and urethra or the rectum back into their normal positions and repairing the vagina.

Both types of repair can be undertaken either as a separate repair or at the same time as a vaginal hysterectomy.

The length of time the operation takes will depend on the surgery undertaken. This can range from 30 – 60 minutes.

At the end of the operation, a catheter may be passed up the urethra into the bladder to rest the bladder for about 48 hours. A vaginal pack made of gauze may also be inserted to prevent post operative bleeding, for 12 -24 hours There will be some discomfort following surgery which will be controlled with pain killers.

The average hospital stay is 3-5 days and normal activities can usually be resumed within 6 weeks.

The vagina may be left slightly narrowed, but this does not usually interfere with sexual intercourse.

Bleeding after menopause

(Postmenopausal bleeding PMB)

Menopause is the time after you have your last period. Because your final periods can be irregular, menopause is confirmed 12 months after your last period. Bleeding or spotting after this point is called postmenopausal bleeding (PMB).

Postmenopausal bleeding needs to be checked out by a doctor. Mostly the cause will be something very simple and treatable but occasionally it is a sign of more serious disease.

It is not normal to bleed or spot 12 months or more after your last period.

Bleeding after menopause is usually a sign of a minor health problem but can sometimes be an early sign of more serious disease.

When detected early, most conditions causing bleeding after menopause (including cancer) can be successfully treated.

What causes bleeding after menopause?

Bleeding after menopause is rarely cause for concern. It does need to be investigated, however, because in very few cases it will be an indicator of something more serious.

In about 90 per cent of cases, a particular cause for bleeding after menopause will not be found. This is not a cause for alarm, if there is a serious problem it will be identified through investigations. Most of the time, postmenopausal bleeding is caused by:

  • inflammation and thinning of the lining of your vagina (called atrophic vaginitis)
  • thinning of the lining of your uterus
  • growths in the cervix or uterus (called polyps) which are usually not cancerous
  • thickened endometrium (called endometrial hyperplasia) often because of hormone replacement therapy (HRT)
  • abnormalities in the cervix or uterus.

These are generally not serious problems and can be cured relatively easily.

However, about 10 per cent of the time, post-menopausal bleeding is linked to cancer of the cervix or uterus and so it is very important to have it investigated.

Diagnostic tests for post menopause bleeding

If you have postmenopausal bleeding it is important to have it investigated.

You will most likely be referred to a gynaecologist who may:

  • ask you questions about the history of your health
  • examine you
  • do a blood test
  • look at the inside of your vagina and cervix using special tongs (called a speculum). At the same time, they may take a tiny sample of your cervix for testing (called a smear) if you are due.
    Before treatment there are a number of tests and investigations your gynaecologist may recommend.
  • An ultrasound of your pelvis to get a picture of your cervix, uterus, endometrium and ovaries. An external ultrasound is a small hand held device (called a transducer) that the doctor will move over you belly. An internal ultrasound is a small wand that the doctor inserts into your vagina to get a better image of your cervix and uterus.
  • A pipelle test to take and test a sample or biopsy of your endometrium. This can be done without anaesthetic in a day clinic with a thin tube (or pipelle) which is put into your uterus (through your vagina) and gently sucks up a small sample of cells.
  • A hysteroscopy to take photos of your cervix, uterus and endometrium. A sample or biopsy of your endometrium may also be taken for testing. A hysteroscopy involves putting a long, narrow instrument (called a hysteroscope) into your uterus through your vagina. It can be done under local or general anaesthetic.

Treating Post menopausal bleeding:

The kind of treatment you have will depend on what is causing the bleeding.

  • Atrophic vaginitis and thinning of the endometrium are usually treated with drugs that work like the hormone oestrogen. These can come as a tablet, vaginal gel or creams, skin patches, or a soft flexible ring which is put inside your vagina and slowly releases the medication.
  • Polyps are usually removed with surgery. Depending on their size and location, they may be removed in a day clinic using a local anaesthetic or you may need to go to hospital to have a general anaesthetic.
  • Thickening of the endometrium is usually treated with medications that work like the hormone progesterone and/or surgery to remove the thickening.

All treatments should be discussed with you so that you know why a particular treatment or test is being done over another.

Ectopic Pregnancy

Medical Treatment of Ectopic Pregnancy

This treatment has been introduced into the clinical practice to avoid surgery, but requires careful follow-up. The follow up means attending for blood tests during the first week and thereafter once or twice weekly until the tests are negative. The schedule of blood tests will be explained to you by the doctor. The treatment has a 90% success rate. If it is not successful we may have to reconsider medical treatment or surgery.

Methotrexate is the drug used to “dissolve” the pregnancy. It is given by injection in the leg or buttock. Methotrexate is also extensively used for a variety of clinical conditions such as psoriasis and some malignancies.

Side effects of the drug are minimal but may include nausea, vomiting and a sore mouth.Rarely,liver hormone may be deranged and blood cells reduced.

During treatment you should avoid:

  • alcohol
  • folic acid containing vitamins – as they may interfere with the treatment
  • - sexual intercourse – as it may cause rupture of the ectopic pregnancy

Before the injection is given to you, you will have some blood tests to ensure you are suitable for the treatment. Again at the end of the first week blood tests will be repeated. If the levels of the pregnancy hormone are not falling, you may need further scan and treatment. Which is why we need to see you until the hormone levels are negative.

The main worry with ectopics is that they may rupture and bleed. This risk exists while the pregnancy hormone persists in the blood. When all of the placental tissue is dissolved the level of the hormone (hCG) will return to normal.

It is very important, therefore, that you come for regular blood tests. If you develop any sharp pains or an increasing discomfort in your abdomen you should immediately phone the hospital of your consultant or Early Pregnancy Unit or the Gynaecology ward.

However, please remember that

  • it is likely that the pain may get a little worse in the first week after the injection
  • as the pregnancy dissolves and the hormone levels fall you will get some vaginal bleeding like a period.

Aftercare

You should avoid pregnancy for three months after the completion of the treatment and follow up – use a reliable barrier or hormonal contraception.

The risk of ectopic pregnancy is generally 1% and the risk of a repeat ectopic pregnancy is 1 in 10. However remember that you still have a much greater chance of having a normal healthy pregnancy. It is the same as after surgical treatment.

In your next pregnancy

You can make an appointment with your consultant or Your GP will be able to refer you to the Early Pregnancy Assessment Unit after confirmation of pregnancy or when you suspect you might be pregnant again. You will be monitored closely because of the previous ectopic pregnancy.

Your feelings

It is entirely normal to feel helpless, isolated and angry with your own self. Depression, guilt and self-blame are very common emotions after the loss of a baby. As time passes, you will be able to deal with your loss more positively. You may find that you are ready to get on with your life quite quickly. If your symptoms continue, you should get in touch with our counsellors who will be able to help you. Your well being is the most important thing.

Allow yourself time to recover physically and emotionally before trying for another baby.

It is worth remembering that counselling is available for you if you with or need to talk at any time in the future.

If you need any further information or advice please do not hesitate to ask the staff.

Contact Details:

The Ectopic Pregnancy Trust
0207733 2653
www.ectopic.org.uk

Endometriosis Information

What is endometriosis?

Endometriosis is a condition where patches of 'womb-lining' (endometrial ) type tissue develop outside the womb. These patches usually form on the outer surface of the womb or the lining of the pelvis or on the ovaries. Womb-lining may also grow too deeply into the womb muscle, this is called adenomyosis.

These areas grow under the influence of natural ovarian hormones but cannot be shed at period time like normal womb lining.

Endometriosis can affect women between puberty and the menopause.

We don’t know why it develops but sometimes several members of one family can be affected.

It is not infectious and is not associated with cancer.

What are the symptoms?

Symptoms include lower abdominal pain worst the week before a period or severe period cramps during bleeding. Periods may be heavy.

Some women describe pain deep inside during or after intercourse.

Areas of endometriosis on the ovaries may cause irregular periods.

Less commonly endometriosis can affect the bowel or bladder and cause pain or bleeding associated with periods.

All these symptoms can have other causes.

Sometimes endometriosis is discovered during investigations for infertility. We think that only severe endometriosis affecting the tubes and ovaries can be blamed for difficulty getting pregnant. Most women with endometriosis will be fertile.

Symptoms vary a lot between individuals, sometimes a small area causes a lot of trouble but sometimes endometriosis is found during unrelated surgery in women with no symptoms at all.

How do I know if I have endometriosis?

Your doctor may suspect endometriosis because of your symptoms and may detect particular abnormalities with an internal examination. However examination may be normal or just show a tender area which could have a number of other causes.

There are no blood tests for endometriosis and usually an ultrasound scan is normal.

Infection swabs and scans may still be useful to look for other causes of symptoms.

The only definite way to make the diagnosis is by laparoscopy. This is an operation under general anaesthetic where a narrow telescope is inserted into the abdomen through a 'keyhole' incision just below the umbilicus.

Although this is usually a straightforward procedure there is a small risk of complications from the anaesthetic and about a 1 in a 1000 risk of accidental damage to the pelvic organs which may lead to major surgery. The risks vary for each individual and are related to body weight and previous medical and surgical problems. A fit and healthy woman could expect to go home the same day and need about a week off work after a diagnostic laparoscopy.

Many women will try treatments for pelvic infection or irritable bowel syndrome for 3-6 months to rule this out before going for a laparoscopy.

What treatments are there?

There are a variety of treatments which need to be chosen on an individual basis depending on the amount and position of the endometriosis and any plans for pregnancy.

Women with mild symptoms may prefer not to have any treatment at all. Sometimes endometriosis will improve without treatment and it will almost certainly improve at the menopause.

Lifestyle changes to improve general health and reduce stress help many women cope with their symptoms and any side effects from treatments.

Anti-inflammatory drugs eg mefenamic acid (Ponstan), ibuprofen (Nurofen), diclofenac (Voltarol) These may reduce pain from endometriosis and can be taken alongside hormonal treatments.

Hormonal treatments

These work by temporarily suppressing natural ovarian hormone fluctuations so that the endometriosis 'shrivels' away. Usually 4-6 months treatment is needed although symptoms may begin to improve after a month. After treatment is stopped the ovaries will begin to work normally again but the endometriosis may not regrow. Treatment does not guarantee a lifetime cure.

  • Combined oral contraceptive pill: This can effectively reduce symptoms and provide effective contraception. Taking the pill every day without a break may give the best results.
  • Progestogen tablets or injection: Taking a steady dose of these female hormones can also reduce symptoms. Most women will not get periods while on treatment but may notice some weight gain or mood changes. The dose in the progesterone only contraceptive pill (mini-pill) is usually too low to work well. Barrier contraception is needed with progestogen tablets.
  • The progestogen coated intrauterine system (Mirena coil) provides contraception and stops or greatly reduces menstrual bleeding after 2-3 months. It may be more effective for pain during periods than at other times.
  • GNRH analogues eg goserelin (Zoladex), leuprorelin (Prostap/Decapeptyl)) These are monthly 'anti-hormone' injections. Most women will have light irregular bleeding or none at all. Menopausal symptoms such as hot flushes are common but can be treated by taking a low dose of HRT at the same time. Barrier contraception is needed during treatment.

Surgical treatments

  • Diathermy or laser ablation can be used to 'burn away' patches of endometriosis or to divide adhesions (bands of scar tissue). Arease of endometriosis and nodules of disease can also be cut out. This is usually done as a laparoscopic (keyhole surgery) operation.
  • Surgical removal of an ovarian endometriotic cyst or the whole ovary. This may be done laparoscopically or may require a bikini line incision.
  • Hysterectomy and possible removal of the ovaries. This may be considered if other treatments have failed and the woman has no plan for pregnancy. A steady dose of HRT would be needed after this until age 50 to prevent hot flushes and osteoporosis (brittle bones). Taking HRT like this is not the same as taking it at an older age where there is a higher risk of breast cancer and thrombosis.

This leaflet is for general information only. Please ask your doctor if you have any questions.

You may wish to contact the endometriosis UK for more information or support:

Endometriosis UK
www.endometriosis-uk.org
Helpline 0808 808 2227

Fibroids

What are Fibroids?

Fibroids are growths made of bundles of muscle fibre that grow in the muscle wall of the uterus (womb). Fibroids start as small lumps of growths that normally grow bigger very slowly, over a few years, but eventually may cause problems. Fibroids can be quite small and you may not know they are there but they can grow large, even to the size of a football in a small number of women.

The main types of fibroids are

  • Intramural fibroids – the most common type, develop in the muscle wall
  • Subserosal fibroids – develop outside the wall of the womb and can become very large
  • Submucosal fibroids – develop in the muscle layer beneath the inner lining of the womb and grow into the middle of the womb
    When subserosal or submucosal fibroids are attached to the womb they are described as pedunculated fibroids.

What causes fibroids?

It is not known what causes fibroids, but it is known that they grow in response to a hormone produced by your ovaries, called oestrogen. Fibroids stop growing and actually shrink after the menopause. They may grow quickly during pregnancy then shrink again afterwards.

Who gets fibroids?

As many as one in five of all women less than 50 years old are thought to have fibroids and they are more common in women around the age of 40 years. Fibroids are more likely to develop if you have a family history of the condition, but you cannot ‘catch’ them or prevent their development. Factors such as taking the combined contraceptive pill, having more full term pregnancies and being slim seem to help prevent fibroids developing.

What are the symptoms?

Many women do not have any symptoms and do not even know that they have fibroids. For some women, fibroids are the cause of a great deal of discomfort and inconvenience. The following list of symptoms may be experienced if you have fibroids.

  • Discomfort, bloating and heaviness.
  • Heavy menstrual bleeding (heavy periods), this is the most common.
  • Pain or pressure: severe cramps, colicky pain, sharp pelvic pain, lower backache.
  • Urinary frequency or altered bowel habit (constipation) due to the fibroid pressing on the bowel or bladder.
  • Infertility (fibroids may be associated with up to 10% of cases).

How are fibroids diagnosed?

Often fibroids are diagnosed by accident. Most commonly your GP will discover that you have fibroids during a routine gynaecology examination. Fibroids may also be detected during investigations for fertility, although they are not usually the main reason for being unable to become pregnant.

At the hospital an ultra sound scan can confirm the diagnosis of fibroids, and exclude other reasons for your symptoms such as problems with your ovaries. The scan helps the doctor assess how many fibroids you have, the exact size and where they are in your womb. The doctor may request a more detailed scan called an MRI that looks in more detail at the fibroids and their blood supply before advising what treatment is best for you.

How are fibroids treated?

This really depends on whether you have any symptoms. There are two main forms of treatment; medical and surgical, and in some cases you may receive both.

Treatment issues that need to be discussed with your consultant, include:

  • Your lifestyle
  • The severity of your symptoms
  • Your age and whether you wish to have children

The aim of your treatment is to improve your quality of life by relieving your symptoms.

It is important that you are involved in the decision on which your treatment will be based.

Medical options

Ii the fibroids are not causing any problems, then you may not need to do anything at all. You may be seen again in 6-12 months time with a repeat scan to establish that the fibroids are not growing.

Hormonal drugs can reduce the amount of oestrogen you have in your body. The aim of this treatment is to improve your symptoms and even reduce the size of your fibroids, but once you stop taking them it is likely that your fibroids will return to their original size within a few months.

GnRh agonist injection: (Decapeptyl/Prostap)

These are hormonal drugs may be given to help reduce the size of your fibroids and are usually given for about three months before surgery. This will help to relieve pain and make the fibroids smaller. It may make the procedure simpler and shorter. They will also stop your periods to allow your blood count to improve.

Hormonal drugs have side effects, most make you feel menopausal.

These will be discussed with you before you start to take them.

If your periods are very heavy due to your fibroids, your doctor can give you a drug to help reduce the monthly bleeding, but this will not affect the size of the fibroids.

Esmya(Ulipristal)

This is a fairly new hormonal tablets that is very effective in reducing menstrual blood loss quickly. It acts on the progesterone receptors in the fibroids. It is also given for 3 months prior to surgery to stop bleeding and reduce fibroid size.

Mirena IUS

In many women a Mirena IUS (coil) device may be appropriate which can be very effective in reducing the amount of menstrual bleeding. You may be offered a hysteroscopy (telescopic examination of the centre of the womb) to ascertain whether a Mirena IUS can be fitted for you, if the fibroids are not distorting the womb too much.

If you suffer from anaemia due to heavy bleeding, the doctor will give you iron tablets. Painkilling medication can help relieve pain from which you may suffer.

Surgical Options

A myomectomy involves the removal of fibroids themselves, whilst keeping your uterus; your ovaries will not usually be removed. In large fibroids this may necessitate a large incision on your tummy, in most cases a ‘bikini incision’. This can be difficult surgery, you may require a blood transfusion. There is even a very small risk of a hysterectomy if the bleeding is severe. You may develop scar tissue (adhesions) afterwards that can cause other problems.

Fibroids can also be removed through key hole surgery (laparoscopic or hysteroscopic routes) which will help you to recover quickly with less post operative pain and discomfort and with smaller scars.

A hysterectomy is a cure for fibroids and you will not experience any further problems from the condition.

Embolisation

Uterine Artery Embolisation (UAE) treatment may be suitable in certain circumstances. It means a referral to a Radiologist,who may offer the treatment after assessment of the fibroids by MRI Scan.

The treatment involves altering the blood supply to the fibroids by injecting a substance into the blood vessel under X-Ray control. It is safe and effective and causes the fibroids to shrink. It may avoid the need for surgery completely.

A similar treatment using Ultrasound waves called Ex-Ablate has been developed.

What if I want to become pregnant?

It is important not to become pregnant during treatment with the hormonal drugs. You are advised to use contraception during this period. You should use non-hormonal methods of contraception, such as condoms or the cap.

If you have had a myomectomy (surgical removal of the fibroid), you can try for a pregnancy after a little time to allow the womb to heal. Most women are able to give birth vaginally once pregnant after a myomectomy. Your gynaecologist will advise you if a Caesarean section is recommended in any future pregnancies.

UAE may not be a suitable option if you are considering children in the future.

Will I be able to have children?

Fibroids are sometimes discovered by the doctor when examining women who have been trying to become pregnant. However, the presence of fibroids is not necessarily the cause of infertility. Depending on their size and where they are, fibroids can affect the uterus itself making conditions wrong for a fertilised egg to implant. In pregnancy, fibroids can sometimes increase the possibility of miscarriage or of the baby being born too early. Labour itself can be difficult if there is a fibroid causing obstruction in the lower part of the uterus. However, pregnancy can occur in women with fibroids and cause no problems for the mother and baby. If you are pregnant, or hoping to become pregnant, your doctor will be able to offer you advice.

Treatment for fibroids will depend on a number of factors. Your doctor will discuss these choices with you and together you can agree the best treatment to suit you and your life style.

Heavy periods (Menorrhagia)

Heavy periods are not usually a sign of anything serious. But they can disrupt your life and make you feel miserable.The good news is that there are several medicines that work well. And if drugs don't help, surgery might be an option.

Do you find heavy periods a problem?

You may find it hard to judge whether your periods are heavy. Even talking to friends about it may not help. Women often have different ideas about what it means to have heavy periods. Here's a list of things that may mean your periods are heavy.

  • You use more than eight to nine pads or tampons (or both pads and tampons) on your heaviest days.
  • You have to wear both a tampon and a pad (double protection).
  • Your period lasts more than six days.
  • You have to get up at night to change your protection.
  • You pass clots of blood.
  • You stain your bedding or clothes despite wearing tampons and pads.
  • You stay at home during your period because you are worried about having an 'accident'.
  • You feel tired, especially during your period. This could mean your body is low on iron. Doctors call this anaemia. It happens when your body is not able to make enough new red blood cells to make up for blood you lost during your period.Your doctor can find out if you have anaemia by testing a sample of your blood. If your red cell count is low, you may need treatment, such as iron tablets, to help you make more red cells.

If your periods are heavy for more than a few months and they're making your life miserable, you may want to get help from your doctor.

How is the diagnosis made?

Your doctor may suggest you have tests to find out what’s causing them.

Blood tests: You may have a blood test to check you have enough iron in your blood.

Ultrasound scan: if your doctor thinks you may have fibroids (non-cancerous growths in your womb).

Pipelle endometrial sample - A sample of the lining of the womb (endometrium) may be obtained to check for abnormalities. This can be done during a vaginal (internal) examination at the outpatient visit, using a very fine plastic tube, which is passed through the neck of the womb (cervix).

Hysteroscopy is a look inside the womb with a small telescope and camera at which time a sample of the lining of the womb is obtained to make sure there is no abnormality within the cells. Common abnormalities such as polyps or fibroids can be detected and be removed at the same time.

If you bleed after sex or have pain or bleed between your periods, it’s important to go to your doctor. Sometimes these can be symptoms of more serious conditions.

What treatments work?

There are several treatments for heavy periods. Some treatments are also contraceptives.

You should decide with your doctor which one might suit you best. If the first treatment you try doesn’t help, your doctor should be able to offer you something else.

Drug treatments

  • Tranexamic acid is one of the best drug treatments for heavy periods. About 6 out of 10 women who take tranexamic acid get lighter periods. Research found that women taking this drug had a better social life and sex life, because their periods were lighter. There are some side effects. About one third of women who take tranexamic acid feel queasy and get leg cramps.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) may be a better option if your periods are painful as well as heavy. Mefenamic acid (brand name Ponstan) is the NSAID most often used to treat heavy periods. Other NSAIDs include diclofenac (Voltarol) and naproxen (Naprosyn). People who have heart problems should not take diclofenac. About half the women who take NSAIDs say their periods get lighter.
    Seven in 10 say NSAIDs help with period pain. NSAIDs can irritate the lining of your stomach, but you might be able to prevent this by taking your tablets with food.
  • Mirena Intrauterine System (IUS) You may want to consider having a coil fitted that gradually releases the hormone progestogen into your womb.You may have heard this called an IUD (intrauterine device). It is also a contraceptive, so you won’t be able to get pregnant if you have one fitted. It reduces bleeding for most women. For some women, this coil stops their periods completely after about 12 months. But you might bleed slightly more during the first few months after you have this coil fitted and you might bleed between periods.You may also feel boated and have tender breasts.
  • The combined contraceptive pill contains the hormones oestrogen and progestogen.
    Obviously it’s not a suitable treatment if you want to get pregnant. It may make your periods lighter as much as NSAIDs do.
    You may get some mild side effects such as queasiness, headaches, tenderness in your breasts, and changes in your weight.
    Etamsylate (brand name Dicynene) is a tablet for heavy periods that you take four times a day from the start of your period until your bleeding stops. Unlike some treatments for heavy periods, etamsylate doesn't affect hormones in your body. It makes periods slightly lighter for some women. But 2 out of 3 women say they wouldn’t use etamsylate again because it didn’t help very much.The National Institute for Health and Care Excellence (NICE), says etamsylate should not be used routinely for heavy periods
  • Progestogen tablets aren’t normally used for heavy periods. But they may be prescribed if you’re having a very heavy or long period, or to prevent bleeding.

Progestogen is the hormone contained in the progestogen-only pill (also called the mini-pill), which is used as a contraceptive. If your periods are heavy, a mini-pill might not be the best choice, as it can make periods heavier. Progestogen tablets can cause headaches, breast tenderness,stomach upsets, tiredness, and bloating.

Surgical treatments

Your doctor will probably recommend surgery for heavy periods only if drug treatments haven’t helped you.

Endometrial Ablation: An operation to remove/destroy just the lining of your womb can make your periods lighter. Some women's periods stop altogether. You won’t need to be cut, as the operation is done through the vagina. This is only suitable for women who do not desire more children and you should carry on using contraceptives.

If you have fibroids, having an operation to remove them (called a myomectomy) might make your periods lighter. This operation can be done through a cut in the abdomen, vaginally or through the keyhole.

Hysterectomy: Having an operation to remove your womb (a hysterectomy) is the only way to be sure that your periods stop completely. But this is a major operation and you should probably try other treatments first.You can’t have children after this operation.You can also have your ovaries and fallopian tubes removed at the same time as your womb. If your ovaries are removed, you’ll get symptoms of the menopause afterwards and you may need to take hormone replacement therapy (HRT).

Laparoscopy

What is Laparoscopy?

Laparoscopy is an operation in which a telescope is inserted through the umbilicus (belly button) to inspect the pelvic organs i.e. uterus (womb), fallopian tubes and ovaries. Diagnostic laparoscopy is used to try and find a cause for symptoms. Laparoscopy may also be therapeutic, when treatment is performed.

Who might benefit from laparoscopy?

Laparoscopy is useful in evaluating pelvic pain, painful periods, painful intercourse and infertility.

How is laparoscopy performed?

  • General anaesthetic is administered.
  • Your bladder is emptied with a catheter.
  • An instrument is introduced through your cervix into your womb so that it can be moved as required to help visualise the pelvic organs.
  • A small cut (1cm) is made inside the umbilicus.
  • A needle is introduced via the incision into the abdominal cavity, which fills the abdomen with gas (carbon dioxide). This allows the pelvic organs to be seen more clearly.
  • The telescope (laparoscope) is inserted.
  • Up to three other small incisions may be made to introduce other necessary instruments into the abdominal cavity.

Which other procedures may be performed during laparoscopy?

  • Treatment of endometriosis – Endometriosis occurs when tissue which resembles the lining of the womb is found in other places e.g. in the pelvis. It may cause painful periods, the pain often starting before the period. Endometriotic deposits have a typical appearance and they may be removed at laparoscopy using either heat (cautery) or by cutting them out (excision).
  • Dye test – this is used for women who are trying to conceive. Blue dye (which is harmless to you) is introduced into the womb from below. The dye should travel up the tubes and spill out of the ends into the pelvic cavity.
  • Adhesiolysis – Adhesions may be caused by previous surgery or infections. Bands of fibrous scar tissue ‘stick’ organs together and may cause pain. If adhesions are not too extensive they may be divided e.g. cut. If adhesions are complicated or extensive you may need a larger open operation at a later date.
  • Removal / aspiration of ovarian cysts, removal of ovaries and fallopian tubes.
  • Ovarian cysts may be removed or aspirated (drained) using laparoscopy. It is sometimes possible to remove ovaries and fallopian tubes.
  • Sterilisation
  • Subtotal hysterectomy

Is it a safe procedure?

Laparoscopy is a relatively safe procedure. However, it does carry some risks. The overall risk of serious complications is 1 in 500. Your risk will be higher if you are obese, have had previous abdominal surgery or have pre-existing medical problems. Possible risks include:

  • Risks from anaesthesia – A separate information leaflet is available about anaesthesia. Your anaesthetist will also be able to answer any questions you may have before the operation.
  • Injury to bowel/bladder/major blood vessels – this may occur on entry into the abdominal cavity with any of the previously mentioned instruments. If necessary, the operation will be converted to a “laparotomy” (i.e. a larger incision will be made on your abdomen) to repair any damage caused.
    The overall risk of serious complications from diagnostic laparoscopy is approximately 2 women in every 1000 (uncommon)
  • You may need to have a blood transfusion if a vessel is damaged. Your hospital stay may be prolonged if these complications occur.
  • Infection – Serious infections of the pelvis are very rare. Minor infections of the wound sites or bladder (cystitis) may occur and usually respond to a course of antibiotics that you can obtain from your GP.
  • Failure to gain entry into the abdominal cavity – this occasionally happens and you may be offered a repeat attempt at laparoscopy or an open operation at a later stage.
  • Uterine perforation – this could happen with the instrument used to move the uterus. Most small holes in the uterus heal by themselves but you may need to be monitored overnight.
  • Unable to identify the cause of your symptoms – Sometimes nothing is found on laparoscopy to account for your symptoms.
  • Bruising – this should settle after about a week
  • Shoulder tip pain – this is fairly common and results from the gas introduced into the abdomen. The gas may irritate a nerve under the diaphragm, which also supplies the shoulder.

Are there alternative diagnostic or treatment options?

  • Pelvic ultrasound - This may be helpful in diagnosing some causes of pelvic pain e.g. ovarian cyst but often cannot be used to diagnose others (eg. endometriosis).
  • Hysterosalpingogram - This is a test to check for blockage of the fallopian tubes and is performed in the x-ray department. Dye (which shows up on x-rays) is injected into the womb and x-rays are taken to see if it has spilled out of the tubes. A laparoscopy and dye has the advantage of checking for endometriosis and is therefore often preferred when a woman has painful periods or intercourse.
  • No treatment - Your gynaecologist will take into account your symptoms, an examination and the results of any tests when considering a laparoscopy. As the procedure is not without risks the patient and doctor have to decide together whether the symptoms warrant a laparoscopy.

What type of anaesthetic is used?

Laparoscopy is performed under a general anaesthetic. It is important to follow the advice on your admission letter and that given by the pre-admission assessment nurse. You will be advised when to stop eating and drinking and whether to stop or continue regular medication. Please follow the pre-operative fasting instructions given by the pre-admission nurse specifically for day surgical procedures to aid recovery.

You should refrain from smoking and drinking alcohol for 48 hours prior to your operation. Please follow the pain relief advice leaflet given by your pre-operative assessment nurse. Please read the instructions on the admission form. Please ask your nurse for the anaesthetic information leaflet.

When will I go home after the operation?

If you have a laparoscopy in the Day Care Unit you will be allowed to go home a few hours after the procedure if there are no complications. You should have emptied your bladder and not been in severe pain or actively bleeding. Patients should not drive for 48 hours after the procedure so private transport home with a companion must be arranged.

When can I go back to work?

People vary in how quickly they recover after surgery. Depending on your job you may be able to return to work 1–3 weeks after the operation, as long as you feel well.

When can I have sexual intercourse?

Once the vaginal bleeding has stopped.

What about the stitches?

Small plasters will be covering your wounds when you wake up. The stitches normally dissolve, but may require removal at your GP’s surgery if still present after 5-7 days. Showers are preferable to baths and dry plasters should cover your wounds for three days, so try not to get them wet. After three days the wounds should be left uncovered and kept clean and dry.

When should I seek urgent medical advice after laparoscopy?

If you experience increasing abdominal pain, distension, high temperature (fever), loss of appetite, nausea or vomiting, this may be caused by damage to your bowel or bladder.

If you develop a painful red swollen leg, shortness of breath, chest pain or start coughing up blood, this may be a sign of a clot in the leg or lung.

In such cases you will need to be admitted to the hospital urgently.

For urgent medical advice please contact the hospital of your treating consultant, your GP or accident and emergency.

Myomectomy (fibroid surgery)

What is a myomectomy?

A myomectomy is a surgical procedure that removes fibroids from the wall of the uterus,without removing the uterus. This is done via a low horizontal (bikini line) incision of the abdomen or a midline incision (vertically) if the fibroids are very large.

A myomectomy is usually performed for one of the following reasons:

  • Heavy periods (menorrhagia).
  • Infertility - women with very large fibroids may have difficulty in getting pregnant.

Women may be advised to have fibroids removed before having assisted conception.

  • Pressure symptoms and discomfort due to an enlarged womb - fibroids may press on the bladder causing the need to pass urine frequently. If very large they can cause the abdomen to swell and feel uncomfortable.

What does the surgery involve?

There are several ways to perform a myomectomy. Laparoscopically (keyhole surgery) or hysteroscopically where the fibroids are removed via the cervix. Many treatments, which once required major surgery, can now be performed through a laparoscope. This means a much quicker recovery, as there are no big incisions on the abdomen.

The method used to perform your myomectomy will depend on the number and size of the fibroids that you have how deeply they are rooted and their location.

Your doctor will discuss this with you in the clinic and when you sign the consent form.

Are there any side effects or possible complications?

The chances of complications of a myomectomy vary slightly with how it is performed, but generally they include:

  • Bleeding: excessive bleeding may occur and it may be necessary to give you a blood transfusion during or after the procedure.
  • Infection: this may require treatment with antibiotics.
  • Injury to adjacent organs: depending on the injury, further surgery may be required and may result in a longer recovery
  • Developing clots in your leg or your lungs: this is not common and you will be advised to mobilise as soon as you are comfortable after your surgery. You may also be given compression stockings to wear and may receive an injection (heparin) to thin your blood whilst you are in hospital.
  • Adhesion formation: scar tissue may occur both in the pelvis and inside the womb following this type of surgery. The chance depends on the type of surgery and the size and number of fibroids that are removed.
  • Hysterectomy (removing the womb): this is uncommon (one in 100 cases) and is only performed in life-threatening situations in order to stop the bleeding.
  • Recurrent fibroids: the chance of new fibroids growing may be as high as 60% over five years. These may be picked up on an ultrasound scan, but are only significant if they are causing problems. Any future surgery may be more difficult because of the scar tissue that may have formed after the myomectomy.

Outpatient Hysteroscopy

Hysteroscopy is usually offered to

  • Find the cause of your problem
  • Provide a diagnosis
  • Begin treatment

...without the need for a general anaesthetic. This means you can return to your normal daily life more quickly.

The Nature of the Procedure

Hysteroscopy is a procedure carried out to look at the inside of the womb (uterus) and can be performed either as a day case or outpatient procedure. A hysteroscope is a thin, telescope-like instrument which is attached to a light source and TV screen. This provides a view to examine your womb lining. Similar to a smear test, the doctor will use an instrument called a speculum which is put into your vagina to enable him or her to see the neck of the womb (cervix). The telescope is then inserted through the cervix into your womb.

Reasons for hysteroscopy include:

  • Heavy or irregular bleeding that has not got better with tablets from your doctor.
  • Bleeding between periods.
  • Infertility cases

Recurrent IVF failure/implantation failure:

  • It may be performed if you are having unexplained miscarriages
  • Suspected uterine polyp on ultrasound scan with period problems
  • Suspicion of scar tissue into the womb (synechiae)
  • Bleeding after your menopause.
  • Irregular bleeding whilst you are taking Hormone Replacement Therapy (HRT).
  • If you are thinking about having an operation to make your periods less heavy
  • (Endometrial ablation or microwave ablation).
  • Division of womb septum
  • Retrieval of a lost birth control coil

Before your Hysteroscopy

You can eat and drink normally on the day of your Hysteroscopy (if it was outpatient procedure without anaesthetic)

Please bring a sanitary towel of your choice just in case you experience any bleeding or discharge after the procedure.

What will happen during and after the Hysteroscopy?

The hysteroscopy itself takes about 10 minutes. You may feel some period type pain, but a lot of women feel nothing at all. You will feel wet due to the water being passed through the telescope. The doctor will explain the findings once again and whether or not you need any medication or another appointment. You can resume normal daily activities by the next morning. Some bleeding may be experienced, though this should be minimal.

Occasionally, depends on the findings you may need to come for another hysteroscopy under general anaesthetic for procedures like like removal of fibroid or polyps or division of adhesions(scar tissue)

Benefits of the Procedure

This procedure will enable the surgeon to view the lining of the womb without the need for a more lengthy operation requiring a cut to the abdomen.

It is also possible to remove polyps and take samples of the lining of the womb during the procedure.

The Risks of the Procedure

A hysteroscopy is a very safe procedure which is performed very frequently. However, on very rare occasions perforation of the womb (making a hole in the wall of the womb) may occur. This may be noted at the time of the procedure but may not require further action. However, depending on the extent of the perforation, a small stitch or a more involved operation may be required. This will be done whilst you are under anaesthetic and will result in a longer stay in hospital so that you can be observed closely. It is extremely rare that you would need to be brought in for an anaesthetic for any stitch or other operation.

Infection is a possible complication, however it is rare. If this should happen you may develop a foul smelling discharge, abdominal discomfort and a temperature.

If you have any of these symptoms, seek advice from your doctor or GP
It is important to note that there is a small possibility that the surgery cannot be completed. This depends on findings at the time of surgery.

Discomforts of the Procedure: do I need an anaesthetic?

Although this procedure is carried out as an outpatient procedure and does not usually require an anaesthetic, not all patients are suitable for this. We suggest that you take a standard dose of a painkiller such as Paracetamol or Ibuprofen about one hour before your appointment to reduce the discomfort. If the procedure is uncomfortable for you or if the opening to your womb is very tight, the doctor may need to inject a local anaesthetic to numb your cervix.

What happens following hysteroscopy?

Sometimes small samples or biopsies are taken; you will be told if this is the case. These will be sent to the laboratory for examination. You will be advised of the results as soon as they are available. If the doctor thinks you require medication he will prescribe this for you before you leave.

If it is necessary to carry out any further surgery or investigations the doctor will advise you of this before discharging you. On discharge you are advised to rest for 2-3 days. You may have some bleeding, though this should be minimal. Pain is usually mild and simple pain killing tablets such as Paracetamol or Ibuprofen are effective in most cases.

How do I get the results?

If small samples or biopsies are taken, you and your GP will be advised of the results by letter as soon as they are available.

Retained Tissue

Any tissue taken at the time of your operation will be sent for examination to the laboratory and your consultant will be informed of the result. Following investigation the tissue will be disposed of in accordance with health and safety. With your permission this may be useful for research or teaching purposes.

When the procedure is completed You should NOT drive yourself home. It is important to arrange for someone to collect you.

The Alternatives to the Procedure
This depends on the reasons for having the investigation. Other possible investigations may be an ultrasound scan or surgery to view the pelvis. The doctor will be happy to discuss any alternative investigation or treatment if they are applicable to you.

What are the most common findings?

  • In many cases we find no serious cause for the bleeding
  • Polyps - these are simple skin tags inside your womb
  • Fibroids - these are lumps in the muscle wall of the womb.
  • Heart shape womb (bicornuate uterus) or septum

What treatment options are available to me?

Polypectomy (Removal of polyps)
Polyps are small fragile growths that can occur in many places, and it may be possible to remove these in the clinic. If polyps are found to be the cause of your bleeding, you will be advised to have them removed. The procedure of removing polyps is called Polypectomy and this can often be performed in the clinic, preventing the need for further surgery. Sometimes if the polyp is too large the doctor will recommend an operation using a general anaesthetic to remove it.

Polyps can be found:

  • On the surface of the cervix/womb (cervical polyp)
  • On the lining of the womb (endometrial polyp)

Polyps can be left alone, although it is usually advisable to remove them as there is a very small chance they can become malignant (cancerous).

Mirena IUS for heavy periods

The Mirena IUS (Intra Uterine System) is a hormone releasing system placed in your uterus and contains a hormone called levonorgestrel. It is a safe, well tolerated and effective treatment for heavy periods. It also provides reliable contraception if required.

Consequences of not having the Procedure

We will not be able to determine the cause of your abnormal bleeding and we may not be able to offer treatment to prevent your symptoms continuing or worsening

Reversal of Sterilisation

What is Reversal of Sterilisation?

Tubal ligation reversal is surgery to reopen, untie, or reconnect a woman's fallopian tubes so she can become pregnant.

The surgery is performed on women who previously had their tubes tied. Women younger than age 30 are more likely to regret having their tubes tied.

Can I Have Tubal Reversal Surgery?

Your consultant will consider the following factors before you both decide if tubal reversal is right for you:

  • Your age
  • The type of tubal ligation surgery you had
  • Your overall health and health of your ovaries, uterus, and remaining fallopian tubes, especially their length

Your doctor will also ask you the following questions:

  • When did you have your tubes tied?
  • What type of tubal ligation did you have?
  • Did you get pregnant before having a tubal reversal, and was it a healthy pregnancy?
  • Had you had surgery in the past for endometriosis, fibroids, pelvic inflammatory disease (PID), or other gynaecological disorders? Surgery can cause scar tissue, which may affect the success of the tubal reversal.

In general, good candidates for tubal reversal are women who had only small parts of their fallopian tubes removed, or whose tubes were closed using clips. Some surgeons say the best candidates for tubal reversal are women younger than age 40 who had sterilization surgery immediately following childbirth, a procedure called postpartum tubal ligation.

Before the Procedure

Before surgery, your doctor will likely recommend a complete assessment for you and your partner to determine if pregnancy can be achieved after a tubal reversal. This may include blood and imaging tests to make sure your ovaries are normal.

A sperm count and semen analysis is recommended for a male partner to rule out any infertility problems.

How Is Tubal Reversal Performed?

Tubal reversal surgery is done in a hospital. You will be given general anaesthesia, which means you will be pain -free during surgery and unaware of the operation taking place.

During the procedure, some surgeons place a small lighted scope, called a laparoscope, through the belly button and into the pelvis area. This allows the surgeon to look at the fallopian tubes and determine if reversal surgery is possible.

If the tubal ligation can be reversed, the surgeon then makes a small surgical cut, called a "bikini cut," near the pubic hair line. Other surgeons may proceed directly to a cut (laparotomy). Microscopic instruments are used to reconnect the ends of the tubes to the uterus, using very small stitches. Your doctor may be able to reconnect one or two sides or unfortunately sometimes both tubes are not suitable for reversal of sterilisation.

The surgery usually takes about two to three hours.

Recovery after a Tubal Reversal

Recovery time depends on the surgical method used to perform the tubal reversal. Tubal reversal is major abdominal surgery that is more difficult and takes longer to perform than the original tube-tying operation.

Some women may need to stay in the hospital for one to three days. Today, however, tubal reversal surgery is most often done using microsurgical techniques. The doctor will prescribe painkillers to help you manage any discomfort. Most women resume normal activities within two weeks.

Pregnancy Success Rates After Reversal

If the remaining fallopian tubes are healthy, and you and your partner do not have any other infertility issues, you have a good chance of becoming pregnant after tubal reversal.

However, not every woman is able to become pregnant after tubal reversal. Age plays an important role in the ability to become pregnant after tubal reversal. Older women are much less likely than younger woman to become pregnant after this procedure. In general, pregnancy success rates range from 40% to 85%. When pregnancy does occur, it usually occurs within the first year. Success depends on several things, including:

  • Your age
  • Type of tubal ligation procedure you had
  • Length of the remaining fallopian tubes, and whether they still work properly
  • Amount of scar tissue in your pelvic area
  • Results of your partner's sperm count and other fertility tests
  • Surgeon's skill

You may need another X-ray dye test (hysterosalpinogram) about three to four months after surgery to make sure your tubes are open and working properly.

Complications and Risks

All surgery carries some risk. Risks are very rare but may include bleeding, infection, damage to nearby organs, or reactions to anaesthesia.

Women who have tubal reversal have an increased risk of ectopic pregnancy; it could be a life-threatening condition in which a fertilized egg grows outside of the womb -- usually inside a fallopian tube. This condition requires immediate medical attention.

In some cases, the area of the tubal reversal forms scar tissue and re-blocks the fallopian tubes.

How Much Does Tubal Reversal Surgery Cost?

Insurance does not typically cover the procedure. Tubal reversal is expensive -- few thousand pounds for the surgery, along with anaesthesia and hospital fees and the cost of fertility tests required before the procedure.

Alternatives to Tubal Reversal Surgery

An alternative to tubal reversal is in Vitro Fertilisation (IVF), a form of assisted reproduction in which a woman's egg and man's sperm are fertilized outside the womb in a laboratory dish. The fertilized egg (embryo) is later placed into a woman's womb. Increasing IVF success rates have led to a decrease in the number of tubal reversal in recent years.

IVF may also be an option for women who cannot achieve pregnancy after tubal reversal surgery.

Ovarian Drilling for Fertility Treatment

Why has my doctor suggested I have ovarian drilling?

Laparoscopic ovarian drilling is a surgical treatment that can trigger ovulation in women with polycystic ovary syndrome (PCOS).You are trying to get pregnant but you have not been able to release eggs after losing weight and using clomiphene, with or without metformin.

What is Polycystic Ovarian Syndrome (PCOS)?

PCOS is a condition which women’s hormones are out of balance and make it difficult to get pregnant. It may affect your periods, ovulation, and appearance. Your ovaries may have many tiny cysts and your androgen (male hormone) level may be increased.

What is Ovarian Drilling?

Ovarian Drilling is a surgical procedure done by keyhole (laparoscopic) surgery on your abdomen. It is done under general anaesthetic and takes around 30 minutes to do. 4 to 6 holes are drilled in each ovary using an electric current. The aim is to destroy the tissue that's producing androgens (male hormones).

Are there other alternatives to Ovarian Drilling?

The alternatives to ovarian drilling are stimulation of your ovaries using fertility hormones injections Follicle Stimulating Hormone (FSH) or Intrauterine Insemination (IUI). Your doctor can discuss these alternatives with you.

How long do I have to stay in hospital and when can I get back to work?

Everyone recovers at a different rate. Ovarian drilling is a routine day case operation and most patients can go home the same day. Very rarely would you have to stay in hospital overnight. Most women are back to normal physical activity including gentle exercise after five days.

What are the benefits/ advantages of Ovarian Drilling and how successful is it?

Approximately 80% of patients who underwent ovarian drilling resumed ovulation, while nearly 50% were able to become pregnant within a year. You are less likely to have twins or triplets compared to other fertility treatments (which are as high as 10%).

What are the Risks of Ovarian Drilling?

Laparoscopic Ovarian surgery is very safe.However; there are risks of laparoscopy such as infection, injury to bowel or bladder or large blood vessels and bleeding. There is a small risk of adhesions forming (scar tissue) on the ovary and affecting your egg reserve and early ovarian failure.

Where is the Evidence of Ovarian Drilling Success?

The National Institute of Clinical Excellence (NICE) recommends ovarian drilling and its advice can be viewed on their website www.nice.org.uk

Are there any patient support groups for PCOS?

The Charity group Verity runs a support network. Information can be obtained from their web-site; www.verity-pcos.org.uk.

Also, speak to your gynaecologist or your GP if there are any questions you need answering.

Polycystic Ovary Syndrome (PCOS)

What is polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is a condition which can affect a woman’s menstrual cycle, fertility, hormones and aspects of her appearance. It can also affect long-term health. This information is about the effects on your long-term health and also specific treatment options.

What are polycystic ovaries?

Polycystic ovaries are slightly larger than normal ovaries and have almost twice the number of follicles (small cysts). Polycystic ovaries are very common affecting 20 in 100 (20%) of women. Having polycystic ovaries does not mean you have polycystic ovary syndrome. Around 6 or 7 in 100 (6 to 7%) of women with polycystic ovaries have PCOS.

What are the symptoms of PCOS?

The symptoms of PCOS can include:

  • Irregular periods or no periods at all
  • Difficulty becoming pregnant (reduced fertility)
  • Having more facial or body hair than is usual for you (hirsutism)
  • Loss of hair on your head
  • Being overweight, rapid increase in weight, difficulty losing weight
  • Oily skin, acne
  • depression and mood swings.

The symptoms may vary from woman to woman. Some women have mild symptoms, while others are affected more severely by a wider range of symptoms. PCOS is a cause of fertility problems in women. You may still become pregnant even if you do not get periods. If you do not want to become pregnant, you should seek advice from your GP about contraception.

What causes PCOS?

The cause of PCOS is not yet known. PCOS sometimes runs in families. If any of your relatives (mother, aunts, sisters) are affected with PCOS, your own risk of developing PCOS may be increased.

The symptoms of PCOS are related to abnormal hormone levels. Hormones are chemical messengers which control body functions. Testosterone is a hormone which is produced by the ovaries. Women with PCOS have slightly higher than normal levels of testosterone and this is associated with many of the symptoms of the condition.

Insulin is a hormone which regulates the level of glucose (a type of sugar) in the blood. If you have PCOS, your body may not respond to the hormone insulin (known as insulin resistance), so the level of glucose is higher. To prevent the glucose levels becoming higher, your body produces more insulin. High levels of insulin can lead to weight gain, irregular periods, infertility and higher levels of testosterone.

How is PCOS diagnosed?

Women with PCOS often have different signs and symptoms and sometimes these come and go. This can make PCOS a difficult condition to diagnose. Because of this, it may take a while to get a diagnosis.

  • Irregular, infrequent periods or no periods
  • More facial or body hair than is usual for you and/or blood tests which show higher testosterone levels than normal
  • An ultrasound scan which shows polycystic ovaries When a diagnosis is made, you may be referred to a gynaecologist (a doctor who specialises in caring for a woman’s reproductive system) or an endocrinologist (a doctor who specialises in the hormonal system).

How is Polycystic ovarian syndrome treated?

Irregular periods

If your main concern is the symptom of irregular periods then the usual treatment is the oral contraceptive pill which will almost always restore regular periods. This treatment is obviously not suitable for women trying to conceive. The oral contraceptive pill can also help the treatment of the acne and hirsutism (more body hair than usual). There is some evidence to show that reduction of excess weight can improve most of the problems related to polycystic ovarian syndrome by helping to restore the normal hormone balance, since fat plays a part in the production of certain hormones.

Infertility

The irregular and infrequent ovulation caused by PCOS can make it difficult to conceive. But remember, you are much less likely to become pregnant if you are obese. If you are obese or overweight then losing weight is advised in addition to other fertility treatments. Ovulation can be stimulated artificially using drugs. The most commonly used drug is clomiphene (Clomid) which is taken in tablet form for 5 days. If the tablets fail, hormone injections such as Menopur or Puregon can be used to stimulate the ovaries. Careful supervision by a specialist is necessary as there is a danger that the ovaries become overstimulated, leading to multiple pregnancy or the potentially life threatening ovarian hyperstimulation syndrome (OHSS).

For women unresponsive to medical treatment, surgery in the form of laparoscopic ovarian diathermy or drilling can be used to burn part of the ovary, thereby correcting hormonal imbalance and allowing ovulation to occur.

Metformin

A medicine called Metformin, which reduces insulin resistance in people with diabetes, It also helps to decrease testosterone level (male hormone level). This may help to restore ovulation and lessen hair growth. Although Metformin is not weight-loss drug, it may help with weight loss.

Excessive hair growth

Local techniques like depilatory creams, shaving, waxing, bleaching, plucking and electrolysis may prove useful but need to be repeated. Suppression of male hormone production with tablets like the oral contraceptive pill (Dianette) or an anti-male hormone drug like cyproterone acetate may reduce excessive hair growth if used for at least 9 months.

What could PCOS mean for my long-term health?

You are at greater risk of developing the following long-term health problems if you have PCOS:

Insulin resistance and diabetes

If your blood glucose does not stay normal, this can lead to diabetes. One or two in every ten (10 to 20%) women with PCOS go on to develop diabetes at some time. Untreated, this causes damage to organs in the body. If you have PCOS, your risk of developing diabetes is increased further if you:

  • Are over 40 years of age
  • Have relatives with diabetes
  • Developed diabetes during a pregnancy (known as gestational diabetes)
  • Are obese (body mass index or BMI over 30)

High blood pressure

Women with PCOS tend to have high blood pressure, which is likely to be related to insulin resistance and to being overweight, rather than the PCOS itself. High blood pressure can lead to heart problems and should be treated.

Heart disease in later life

Developing heart disease is linked to health conditions like diabetes and high blood pressure. If you have a high cholesterol level you may be advised to take medication (statins) to reduce the risk of heart problems. If you are trying for a baby, you should seek specialist advice about the use of statins.

Cancer

With fewer periods (less than three a year), the endometrium (lining of the womb) can thicken and this may lead to endometrial cancer in a small number of women.

There are different ways to protect the lining of the womb using the hormone progestogen. Your doctor will discuss the options with you. This may include a five-day course of progestogen tablets used every three or four months, taking a contraceptive pill or using the intrauterine contraceptive system (Mirena). The options will depend on whether you are trying for a baby. PCOS does not increase your chance of breast, cervical or ovarian cancer.

Depression and mood swings

The symptoms of PCOS may affect how you see yourself and how you think others see you. It can lower your self-esteem.

What can I do to reduce these health risks?

Have a healthy lifestyle

The main ways to reduce your overall risk of long-term health problems are to:

  • Eat a healthy balanced diet. This should include fruit and vegetables and whole foods (like wholemeal bread, whole grain cereals, brown rice, wholewheat pasta), lean meat, fish and chicken. You should decrease sugar, salt, caffeine and alcohol (14 units is the recommended maximum units a week for women)
  • Eat meals regularly especially including breakfast
  • Take exercise regularly (30 minutes at least three times a week)

Your GP or specialist nurse will provide you with full information on eating a healthy diet and exercise.

You should aim to keep your weight to a level which is normal (a BMI between 19 and 25). BMI is the measurement of weight in relation to height. If you are overweight, it would be helpful to lose weight and maintain your weight at this new level. If you are obese (BMI greater than 30), discuss strategies for losing weight, including weight-reducing drugs, with your GP, practice nurse.

The benefits of losing weight include:

  • A lower risk of insulin resistance and developing diabetes
  • A lower risk of heart problems
  • A lower risk of cancer of the womb
  • More regular periods
  • An increased chance of becoming pregnant
  • Reduction in acne and a decrease in excess hair growth over time
  • Improved mood and self-esteem

Have regular health checks

Once you have a diagnosis of PCOS, you will be monitored to check for any early signs of health problems.

Women with PCOS over the age of 40 should be offered a blood sugar test once a year to check for signs of diabetes. If you are obese (BMI over 30) or have a family history of diabetes, you may be offered testing for diabetes earlier than age 40.

If you have not had a period for a long time (over 3 months), it is advisable to see your doctor. You may be offered a referral for further tests which may include an ultrasound scan. Discuss with your doctor how often you should have your blood pressure checked and whether you should have blood tests for cholesterol levels.

Is there a cure?

There is no cure for PCOS. Medical treatments aim to manage and reduce the symptoms or consequences of having PCOS. Medication alone has not been shown to be any better than healthy lifestyle changes (weight loss and exercise). Many women with PCOS successfully manage their symptoms and long-term health risks without medical intervention. They do this by eating a healthy diet, exercising regularly and maintaining a healthy lifestyle.

Useful contacts

The Polycystic Ovary Self Help Group
www.verity-pcos.org.uk
Infertility Network UK
Charter House
43 St Leonards Road
Bexhill on Sea
East Sussex
TN40 1JA

Telephone: 0800 008 7464

Website: www.infertilitynetworkuk.com

Pelvic Pain

Chronic Pelvic pain is felt below your bellybutton and it has present for at least 6 months . It may come on suddenly and severely, or could be mild and last for months.

Persistent or recurrent pelvic pain

If you've had pelvic pain for six months or more that either comes and goes or is continuous, it is known as chronic pelvic pain. Chronic pelvic pain is more intense than ordinary period pain and lasts for longer. It affects around one in six women.

If you have chronic pelvic pain, see your doctor to find out the cause and to get any necessary treatment.

Common causes of chronic pelvic pain

The most common causes of chronic pelvic pain are:

  • endometriosis – a long-term condition where small pieces of womb lining are found outside the womb (such as on the ovaries)
  • chronic pelvic inflammatory disease – a bacterial infection of the womb, fallopian tubes or ovaries, which often follows a chlamydia or gonorrhoea infection and needs treatment with antibiotics
  • irritable bowel syndrome – a common condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation
  • Pelvic adhesions: Abnormal scar tissue from previous infection, endometriosis or surgery that causes internal organs and structures to stick together
  • Less common reasons for chronic pelvic pain

Less common causes of chronic pelvic pain include:

  • recurrent ovarian cysts – fluid or blood-filled sacs that develop on the ovaries
  • a recurrent urinary tract infection
  • lower back pain
  • prolapse of the womb – the womb slips down from its normal position and usually causes a "dragging" pain
  • adenomyosis – endometriosis that affects the muscle of the womb, causing painful, heavy periods
  • fibroids – non-cancerous tumours that grow in or around the womb
  • Interstitial cystitis – long-term inflammation of the bladder with bladder pain and a need to urinate both urgently and frequently
  • inflammatory bowel disease – a term used to describe two chronic diseases, ulcerative colitis and Crohn's disease, which affect the gut
  • a hernia – where an internal part of the body pushes through a weakness in the surrounding muscle or tissue wall
  • trapped or damaged nerves in the pelvic area – these may cause sharp, stabbing or aching pain in a specific area, which often gets worse with certain movements

How is the diagnosis made?

Detailed information about your symptoms recorded in a pain diary is the first step in making a diagnosis. Your description of the pattern of pain can often provide much more valuable information than laboratory tests.

  • Laboratory tests may be useful to exclude infection
  • Pelvic ultrasound scan may identify ovarian cysts and fibroids
  • Laparoscopy may be helpful in identifying causes such as endometriosis and chronic pelvic inflammatory disease. This is a surgical procedure where a thin telescope with a camera is passed through a small cut in the belly button to inspect the pelvic structures.

What treatment may help?

Gynaecological conditions are often treated medically but surgery may be necessary in some instances. Hormonal treatment is given for endometriosis and stepwise analgesia is offered to alleviate pain. Surgical treatment of endometriosis may be beneficial in selected cases.

Bladder problems require specialist input from the urologists and involvement of physiotherapists for management of pelvic floor pain can be quite successful.

Psychological counselling or referral to specialist pain management teams may be required to manage chronic pelvic pain if no underlying cause is identified. Complimentary therapy may also be helpful

For more information – www.pelvicpain.org.uk

Recurrent Miscarriage (RM)

A summary of causes, tests and treatment

Information leaflet

The aim of this leaflet is to explain what is currently known about the possible causes of Recurrent Miscarriage,the tests that may be offered to you and your partner, and the treatment available.

What is recurrent miscarriage?

A miscarriage is when you lose a pregnancy at some point in the first 23 weeks. When this happens three or more times doctors call this recurrent miscarriage. For women and their partners it is a very distressing problem.

Around one woman in every 100 has recurrent miscarriages. This is about three times more than you would expect to happen just by chance, so it seems that for some women there must be a specific reason for their losses. For others, however, no underlying problem can be identified; their repeated miscarriages may be due to chance alone.

What are my chances of success in my next pregnancy?

Most couples who have had recurrent miscarriages still have a good chance of a successful birth in future. The older you are, the greater your risk of having further miscarriage.The more miscarriages you have had already,the more likely you will be to have another one.However,even at or above the age of 40 ,there is still a 50% chance of achieving a successful pregnancy.

Table 1: Predicted probability of a successful pregnancy occurring subsequently following miscarriage:

Age (years) Number of Miscarriages
2 3 4 5
20 92 90 88 85
25 89 86 82 79
30 84 80 76 71
35 77 73 68 62
40 69 64 58 52
45 60 54 48 42

References

Bricker L & Farquharson RG (2000) Recurring miscarriage. The Obstetrician and Gynaecologist 2: 17-23

What will happen during my appointment?

You and your partner will be initially seen in RM clinic by Mr Faraj who will take details of your medical history and request blood tests for you and your partner(if necessary).You will have the opportuinity to ask questions you may have.Results of investigations taken should be available within few weeks and you will be contacted with a follow up appointment.At this appointment,your own personal care plan for your next pregnancy will be devised.This may include a viability scan at 7 weeks and sometimes medications.Supportive care from the beginning of your pregnancy will improve the chances of a successful outcome but both your partner and yourself may also need to modify your lifestyles

Key points

If you have had recurrent miscarriages, you may be offered blood tests and/or a pelvic ultrasound scan to try to identify the reason for them.

Your doctors will not be able to tell you for sure what will happen if you become pregnant again.

Why does it happen?

Often, in spite of careful investigations, the reasons for recurrent miscarriages cannot be found.

Approximately 50% of couples with a history of recurrent miscarriage will not have a cause identified even after detailed investigations have been performed

However, if you and your partner feel able to keep trying, you still have a good chance of a successful birth in future.

In summary, no news of an abnormal test result is usually good news.

There are a number of things which may play a part in recurrent miscarriage.

Your age and past pregnancies

The older you are, the greater your risk of having a miscarriage. The more miscarriages you have had already, the more likely you will be to have another one.

Genetic factors

For around three to five in every 100 women who have recurrent miscarriages, they or their partner have an abnormality on one of their chromosomes (the genetic structures within our cells that contain our DNA and the features we inherit from our parents). Although such abnormalities may cause no problem for you or your partner, they may sometimes cause problems if passed on to your baby.

Polycystic ovaries

If you have polycystic ovaries your ovaries are slightly larger than normal ovaries and produce more small follicles than normal. This may be linked to an imbalance of hormones. Just under half of women with recurrent early miscarriages have polycystic ovaries; this is about twice the number of women in the general population.

Having polycystic ovaries is not a direct cause of recurrent miscarriage and it does not mean that you are at any greater risk of further miscarriages. We are not sure what the link is.

Many women with polycystic ovaries and recurrent miscarriage have high levels of a hormone called luteinising hormone (LH) in their blood. Reducing the level of LH before pregnancy, however, does not improve your chances of a successful birth.

Hormones

Follicle stimulating hormone (FSH) drives the ovary to recruit the follicles. Sadly some women with a history of pregnancy loss are also found to have high FSH levels because their ovaries have become prematurely menopausal. Although rare, this is obviously a very important problem to identify, which is why we arrange to check your FSH levels at an early stage of the investigations. If they are high we will arrange for you to be seen by our fertility specialists.

Abnormalities in the embryo

An embryo is a fertilised egg. An abnormality in the embryo is the most common reason for single miscarriages. However, the more miscarriages you have, the less likely this is to be the cause of them.

Autoimmune factors

Antibodies are substances produced in our blood in order to fight off infections. Around 15 in every 100 women who have had recurrent miscarriages have particular antibodies, called antiphospholipid antibodies (aPL), in their blood; fewer than two in every 100 women with normal pregnancies have aPL antibodies. Some people produce antibodies that react against the body's own tissues; this is known as an autoimmune response and it is what happens to women who have aPL antibodies. If you have aPL antibodies and a history of recurrent miscarriage, your chances of a successful pregnancy may be only one in ten.

There are other blood clotting conditions which are hereditary. These include Factor V Leiden, Prothrombin gene mutation, acquired activated protein C resistance, Protein C or S deficiency which are not only associated with recurrent miscarriages but increase the risk of thrombosis. Hence it is important to investigate thoroughly and offer appropriate treatment in pregnancy as well as prophylactic anti-thrombotic drugs during the postpartum period.

Womb structure

It is not clear how far major irregularities in the structure of your womb can affect the risk of recurrent miscarriages. Estimates of the number of women with recurrent miscarriage who also have these irregularities range from two out of 100 to as many as 37 out of 100. Women who have serious anatomical abnormalities and do not have treatment for them seem to be more likely to miscarry or give birth early. Minor variations in the structure of your womb do not cause miscarriages.

Weak cervix

In some women the entrance of the womb (the cervix) opens too early in the pregnancy and causes a miscarriage in the third to sixth month. This is known as having a weak (or ‘incompetent') cervix. It is overestimated as a cause of miscarriage because there is no really reliable test for it outside of pregnancy.

It is most commonly diagnosed based on the medical history of a painless miscarriage and the elective insertion of a cervical suture is often recommended.

Infections

If a serious infection gets into your bloodstream it may lead to a miscarriage.

it is unlikely to be the cause for recurrent early miscarriages.

If you get a vaginal infection called bacterial vaginosis early in your pregnancy, it may increase the risk of having a miscarriage around the fourth to sixth month or of giving birth early. It is not clear, though, whether infections cause recurrent miscarriage; for this to happen, the bacteria or virus would need to be able to survive in your system without causing enough symptoms to be noticed. This rules out illnesses like measles, herpes, listeria, toxoplasmosis and cytomegalovirus (so you do not need to be tested for them if you have recurrent miscarriages).

Blood conditions

Certain inherited conditions mean that your blood may be more likely to clot than is usual. These conditions are known as thrombophilia. They do not, though, mean that a serious blood clot will inevitably develop. Although thrombophilia has been thought to play some part in miscarriage, we do not yet know enough about how or why that is.

Alloimmune reaction

Some people have suggested that some women miscarry because their immune system does not respond to the baby in the usual way. This is known as an alloimmune reaction. There is no clear evidence to support this theory.

Diabetes and thyroid problems

Diabetes or thyroid disorders can be factors in single miscarriages. They do not cause recurrent miscarriage, as long as they are treated and kept under control.

What can be done?

Supportive antenatal care

Women who have supportive care from the beginning of a pregnancy have a better chance of a successful birth. There is some evidence that attending an early pregnancy clinic (if there is one in your area) can reduce the risk of further miscarriages.

Screening for abnormalities in the structure of your womb

You should be offered a pelvic ultrasound scan to check for and assess any abnormalities in the structure of your womb, so that they can be treated if necessary.

Another method of screening using hysterosalpingography (an X-ray of the fallopian tubes using fluid injected through the entrance of the womb) has no advantages over pelvic ultrasound and causes more discomfort, so it is not always necessary.

  • Women with an abnormal baseline pelvic scan indicating a subseptated uterus, a history of high order recurrent miscarriages (≥ 5) or numerous previous surgical evacuation of the product of conception (ERPCs) will be offered further investigations such as a Hysteosalpingogram (HSG). You will be given a consultation to discuss the findings on your HSG and the potential benefit of undergoing further procedures such as a Hysteroscopy with or without surgical correction of uterine abnormalities such as a uterine septum. Both HSG and hysteroscopy are performed in the first half of the menstrual cycle.
  • If you do opt to have a hysteroscopy +/- surgical procedures, you will be admitted to the Day surgery unit. These procedures are normally performed under General anaesthesia.

Screening for genetic problems

You and your partner should be offered a blood test to check for chromosome abnormalities; the test is known as karyotyping. If either or both of you turn out to have an abnormality you should be offered the chance to see a specialist called a clinical geneticist. They will tell you what your chances are for future pregnancies and will explain what your choices are. This is known as genetic counselling. It can help you decide what you want to do for the future.

If it seems likely that other members of your family could be affected by the same problem, they too may be offered genetic counselling.

Screening for abnormalities in the embryo

If you have a history of recurrent miscarriage and you lose your next baby, your doctors may suggest checking for abnormalities in the embryo or the placenta afterwards. They will do this by checking the chromosomes of the embryo through karyotyping, although it is not always possible to get a result. They may also examine the placenta through a microscope. The results of these tests may help them to identify and discuss with you your possible choices and treatment.

Screening for vaginal infection

If you have had miscarriages in the fourth to sixth month of pregnancy or if you have a history of going into labour prematurely, you may be offered tests (and treatment if necessary) for an infection known as bacterial vaginosis (BV).

If you have BV, treatment with antibiotics may help to reduce the risks of losing your baby or of premature birth. There is not enough evidence to be sure that it makes any difference to the chances of a baby surviving.

Treatment for aPL antibodies

There is some evidence that if you have aPL antibodies and a history of recurrent miscarriages, treatment with low-dose aspirin tablets and low-dose heparin injections in the early part of your pregnancy may improve your chances of a live birth up to about seven in ten (compared to around four in ten if you take aspirin alone and just one in ten if you have no treatment).

Even with treatment, you will have a risk of extra problems during pregnancy (including pre-eclampsia, restriction in the baby's growth and premature birth). You should be carefully monitored so that you can be offered appropriate treatment for any problems that arise.

Steroids (certain sorts of natural or synthetic hormones) have been used to treat aPL antibodies in recurrent miscarriage, but they do not seem to improve the chances of a successful delivery and they carry significant risks for you and your baby, compared with aspirin and heparin.

Treatment for thrombophilia

Although you may have a higher risk of miscarriage if you have an inherited tendency to blood clotting (thrombophilia), you may still have a healthy and successful pregnancy. At present there is no test available to identify whether you will miscarry if you have thrombophilia. You may, though, be offered treatment to reduce the risk of a blood clot.

Tests and treatment for a weak cervix

If you have a weak cervix, a serial cervical ultrasound scans during your pregnancy may indicate whether you are likely to miscarry.

If you have a weak cervix you may be offered an operation to put a stitch in your cervix, to make sure it stays closed. It is usually done through the vagina, but occasionally it may be done through a ‘bikini line' cut in your abdomen, just above the line of the pubic hair.

Although having a cervical stitch after the third month of pregnancy slightly lowers your risk of giving birth early, it has not been proved to improve the chances of your baby surviving. Because all operations involve some risk, your doctors should only suggest it if you and your baby are likely to benefit. They should discuss the risks and benefits with you.

Hormone treatment

It has been suggested that taking human chorionic gonadotrophin hormone early in pregnancy could help prevent a miscarriage. There is not yet enough evidence to prove whether this works.

Natural Progesterone (Cyclogest)

There is more emerging evidence that pregnancy may fail due to low progesterone support in early pregnancy (Luteal phase insufficiency).Hence there is an ongoing trial to prove that (PROMISE Trial). Cyclogest is a natural progesterone that may be used from early pregnancy up to 12 weeks in women with unexplained recurrent miscarriage with good results. That medication is still unlicensed but the evidence suggests it could work in high group of women.

Immunotherapy

Treatment to prevent or change the response of the immune system (known as immunotherapy) is not recommended for women with recurrent miscarriage. It has not been proven to work, does not improve the chances of a live birth and it may carry serious risks (including transfusion reaction, allergic shock and hepatitis).

General

  • There is some evidence that women who smoke are at increased risk of miscarriage and this risk is related to the number of cigarettes smoked.
  • Similarly, alcohol consumption has been associated with an increased risk of miscarriage even in moderate amounts (3-5 units per week).
  • There have been studies linking caffeine intake to an increased miscarriage risk. This risk is dependent on the quantity of caffeine intake. The current advice is stop or reduce caffeine intake during pregnancy.
  • Drug intake such as cocaine or heroine confers an independent risk of pregnancy loss.
  • In a recent study, obesity (BMI ≥ 30 kg/m2) was shown to be an independent factor associated with a 73% increased risk of a further miscarriage in women with recurrent miscarriage. Obese women are advised to lose weight prior to conception to reduce their risk of a further miscarriage.
  • Advanced maternal age is known to be associated with an increased risk of chromosomal abnormalities such as Down’s syndrome. However there are many other chromosomal abnormalities that are incompatible with life and will result in first trimester miscarriage. The risk of chromosomal abnormalities increases gradually from age 35 and above but more dramatically at age 40 and above.
  • There is now some evidence suggesting that advanced paternal age increases the risk of miscarriage.

All the above risks are usually associated with sporadic miscarriage rather than recurrent miscarriage. Therefore it is likely that your next pregnancy will be successful. However, it is important to follow the above advice and maintain a healthy lifestyle to reduce your risk of a further miscarriage.

  • Guidelines from the Department of Health suggest that all women planning a pregnancy should take 400 micrograms of Folic Acid before pregnancy until approximately 12 weeks gestation. This is to prevent defects such as spina bifida rather than miscarriage itself. If you are diabetic or have a previous history of neural tube defect, you would need to consult your GP for a higher dose of Folic Acid.

What could it mean for me in future?

Your doctors will not be able to tell you for sure what will happen if you become pregnant again. However, even if they have not found a definite reason for your miscarriages, you still have a good chance (three out of four) of a healthy birth.

Other organisations

These organisations offer support.

The Miscarriage Association
Clayton Hospital
Northgate
WAKEFIELD WF1 3JS
Tel: 01924 200 799
www.miscarriageassociation.org.uk

Women's Health
52 Featherstone Street
LONDON EC1Y 8RT
Tel: 0845 125 5254
www.womenshealthlondon.org.uk

This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) Guideline no 17’’ The investigation and Treatment of Couple with Recurrent Miscarriage’’,2003.

Investigations

Day 2 FSH/LH and Testesterone
Chromosome analysis on both your self and your partner
Lupus anticoagulants and Anticardiolipin antibodies (IgG &IgM)
(if abnormal to be repeated in 6 weeks)
Thrombophilia screen (factor V Leiden,Prothrombin gene mutation,acquired activated proten C resistance,Protein C and Protein S)
Blood Group
Rubella status
Ultrasound scan of your uterus and ovaries

Vaginal hysterectomy / Vaginal repair

What does the surgery involve?

A vaginal hysterectomy is the removal of the uterus (womb) and the cervix through a small cut in the top of the vagina. Removal of the ovaries is sometimes possible although not commonly done at the same time. The usual reasons for performing a vaginal hysterectomy are heavy periods or a prolapsed womb. Not all women are suitable for a vaginal hysterectomy and it can be difficult if the womb is enlarged or if you have not had vaginal births. It is not usually possible to remove the ovaries during a vaginal hysterectomy.

A vaginal repair is an operation for women who have a prolapse. It may sometimes be performed to treat stress incontinence (leaking urine when laughing, coughing, sneezing etc). It involves making a cut in the vaginal wall and closing the skin closer together to reduce the bulge in the vaginal wall. When the operation is performed to treat a prolapse of the front wall of the vagina it is called an anterior vaginal repair. An operation to treat a prolapse of the back wall is called a posterior vaginal repair.

Vaginal hysterectomy and vaginal repairs can be performed either on their own or as a combined operation.

What is a prolapse?

A prolapse is due to a weakness which causes a bulge in the vagina. It may involve the womb alone, the vagina alone, or both the womb and the vagina. There are three common types of vaginal prolapse; cystocele, rectocele and enterocele. The surgery that is performed will depend on the type of prolapse.

  • A cystocele is a bulge in the front wall of the vagina which allows the bladder to move downwards
  • A rectocele is a bulge in the back wall of the vagina which allows the back passage (rectum) to move downwards.
  • An enterocele is a less common type of prolapse in which the small bowel bulges down through the vagina.

Alternatives to surgery

  • A hysterectomy is not usually performed for period problems, unless other more simple treatments have been tried. Alternative treatments include tablets, a Mirena coil and endometrial ablation.
  • Stress incontinence can often be controlled by pelvic floor exercises, supervised by a physiotherapist. In the absence of a large prolapse, surgical treatment usually involves the insertion of a tape below the urethra.
  • Prolapse can often, but not always, be controlled by a plastic pessary inserted into the vagina. However, a pessary is not usually suitable for women who want to remain sexually active.

What should I do before the operation?

You will usually come to the hospital a few days before the operation and have simple tests to make sure you are fit for surgery. Smoking increases the risk of complications so, if possible, please try to stop smoking a month before the operation.

You will be admitted to hospital on the day of the operation where you will be seen by your doctor, who will be able to answer any questions or worries that you might have. Also an anaesthetist will come and discuss with you the options of a general anaesthetic where you to sleep, or regional anaesthesia (like an epidural).

What happens during surgery?

  • A ‘drip’ will be placed in your arm or hand to give you any fluids or drugs that you might need.
  • The operation takes between 30 and 100 minutes.
  • A small tube will be put in your bladder to drain urine. This is called a catheter.
  • A gauze pack may be put in the vagina to prevent bleeding.

What happens after surgery?

You will be taken to the recovery room and kept there until you are fully awake and stable; then you will be taken back to the ward. You will be given pain relief to keep you comfortable. There are different ways of treating any pain you might have, from injections, tablets to suppositories. Another method is called Patient Controlled Analgesia (PCA) and it lets you press a button attached to a pump containing the medicine. This pump is specially built to prevent you giving yourself too much medication. You will receive daily injections of Clexane, a drug which “thins” the blood to help prevent clots forming in your legs.

It is usual to feel some pain or discomfort after a major operation but we will try hard to minimise this. Assuming you are eating and drinking normally, the drip will be removed after 24-48 hours. If you have a vaginal pack, it will usually be removed on the day following surgery. The catheter will normally be removed from your bladder after 1-2 days.

How will it affect me?

You can expect to stay in hospital for around 2-3 days, whilst you gradually get back to normal. Once you are ready for home you will be given a supply of pain relief if required. It is common to feel more tired after any major operation, and it is important to keep mobile but take it easy. You should avoid heavy lifting and strenuous exercise for about 3 months. You should check with your insurance company if you feel able and wish to drive before 6 weeks. The time before you can return to work will depend on your job and you can discuss this with your doctor.

You should have a check-up approximately 6-8 weeks after the operation and your surgeon will decide whether this will be at the hospital or by your GP. You will be advised when other normal activities can be resumed, such as sport and sexual intercourse. Removing your uterus should not affect your sex drive (libido) and you can usually resume sexual intercourse after your check-up.

Potential complications of hysterectomy

Every treatment has its benefits, but there are also possible risks that you should be aware of before you agree to having a hysterectomy. The risk of serious complications increases with age and also if you have other significant medical problems.

Rare but potentially serious risks

  • Injury to the bladder or bowel or ureter (the tube between the kidney and bladder).
  • Bleeding needing a blood transfusion.
  • Going back to theatre to control bleeding or repair injury. This may require a cut in your abdomen.
  • Serious infection in the pelvis or in the bloodstream.
  • Thrombosis – a blood clot in the leg or lung.

More frequent but less serious risks

  • Minor infections eg of chest, bladder, wound, pelvis.
  • Collection of blood (haematoma) in the pelvis.
  • Persistent abdominal pain which can be related to adhesions within the pelvis.
  • You may find it difficult to empty your bladder properly after surgery, especially if an anterior vaginal repair is performed. A catheter may need to be put back into the bladder if this happens. On very rare occasions you may need to use a catheter on a permanent basis.
  • Some women pass urine more frequently than before the operation.
  • Approximately 1 in 20 women who have an anterior vaginal repair will develop stress incontinence (urine leakage with coughing, exercise etc) as a new symptom after the operation. Treatment of this may require further surgery.
  • Women who have a posterior vaginal repair may notice some narrowing or shortening of the vagina. This may be more obvious if an anterior vaginal repair is performed at the same time. This can result in pain or difficulty during sexual intercourse. This can usually be avoided, but perhaps at the expense of increasing the risk of recurrent prolapse (see below). You will be asked about your desire to remain sexually active before the operation.
  • Women who have an operation for prolapse have a risk of developing another prolapse in the future. This is because their body tissues are already weak, having usually been damaged during pregnancy and childbirth.

Additional procedures that may be necessary during your operation

Blood transfusion – if you suffer with increased bleeding during or after your hysterectomy, it may be necessary to give you a blood transfusion. About 15 women out of every 1000 having this operation will need blood. If you feel strongly against this then please discuss it with your doctor beforehand.

Repair of bowel, bladder or ureter – this will be in the rare event of any injury to these organs during the operation.

The control of bleeding or the repair of an injured internal organ may require a laparotomy to be performed. This is an incision in your lower abdomen.

It is important to remember that extra procedures during the course of your hysterectomy will only be done if it is necessary to save your life or prevent serious harm to your future health.

Further information

Contact your gynaecologist
Hysterectomy Association
60 Redwood House,
Charlton Down,
Dorchester,
Dorset DT2 9UH.
www.hysterectomy-association.org.uk