Chronic Pelvic Pain
Cramps during periods (Dysmenorrhea)
Abnormal Uterine Bleeding
Overgrowth of the uterine lining (hyperplasia)
Pelvic Congestion Syndrome
Polyps (Uterine Polyps)
Tubal Pregnancy (Ectopic Pregnancy)
Fibroids are benign tumor-like growths in the muscle walls of the uterus. There are several different types, classified by where they grow:
- Just below the lining of the uterus (submucosal)
- In the middle of the uterine wall (intramural)
- Under the outer covering of the uterus (subserosal)
- On a stalk either inside or outside the uterus (pedunculated)
Fibroids are often the cause of menorrhagia (heavy menstrual bleeding), pelvic pain and pelvic pressure. In rare cases, depending on the location of the fibroids, they may interfere with a woman's ability to become pregnant. Sometimes fibroids grow in a place where they push against the bladder, causing frequent urination.
Fibroids are extremely common. As many as 80% of African American women and 70% of Caucasian, Hispanic and Asian women develop uterine fibroids by the time they are 50. However, most fibroids are small, are not bothersome and do not require treatment.
In about a third of women who have them, fibroids grow large enough to be detected by a physician during a gynecological exam. Even among these women, 80% will never have symptoms or require treatment.
The risk of developing fibroids increases with age until menopause. Most fibroids are diagnosed in women who are between the ages of 40 and 44. After menopause, fibroids shrink.
Fibroids need the female hormones -- estrogen and progesterone -- in order to grow, but what causes them in the first place remains a mystery. Neither is it known why some fibroids grow quickly and some grow slowly. Medical studies are underway to help shed light on these questions.
Fibroid myths and truths
Many women fear that fibroids are problematic than they actually are. Careful analysis of the data on women with fibroids has revealed some welcome truths.
Myth: Fibroids cause infertility.
Fact: One type of fibroid, the submucosal type that bulges into the uterine cavity, has been found to interfere with a woman’s ability to become pregnant. This can be treated effectively with minimally invasive surgery on an outpatient basis.
Myth: Fibroids cause preterm labor.
Fact: The vast majority of women who are pregnant and have fibroids go on to have full-term, healthy babies.
Myth: Pregnant women with fibroids have to deliver by cesarean section.
Fact: Unless a fibroid is growing in a location that blocks the birth canal, pregnant women with fibroids do not need to have a cesarean section.
Myth: Fibroids that are growing rapidly mean cancer is present.
Fact: The kind of cancer that is sometimes mistaken for a fibroid, called leiomyosarcoma, is rare. It has been found in only one out of every 1,000 women admitted to the hospital for fibroid surgery.
Myth: Women with fibroids need a hysterectomy.
Fact: Most women with fibroids require no treatment at all; however, the growth of fibroids should be monitored by a gynecological exam every 3-6 months. If fibroids become very large and bothersome, or if they cause medical problems, a woman may choose among several treatment options.
Fibroids are often diagnosed during a routine pelvic examination because the doctor can feel them or because the uterus is enlarged. They can be mapped by a sonogram or magnetic resonance imaging (MRI). Another diagnostic technique is hysteroscopy, which enables the doctor to see fibroids on the inside of the uterus.
When is surgery needed?
In many women, fibroids cause no symptoms and do not require any treatment. Some women may choose to have treatment because they are bothered by discomfort from fibroids or by consequences such as bladder pressure. However, the only fibroids that actually require treatment are those that cause medical problems, such as severe bleeding and anemia and uncontrollable cramping with bleeding; blocking the ureters with possible damage to the kidneys; or the presence of cancer. The latter two are extremely rare.
Several medicines are available to shrink fibroids; however, their effects are temporary, and when the medicine is discontinued, the fibroids will grow back.
Removal of the fibroid is called myomectomy. Medical advances have made it possible to remove fibroids using minimally invasive surgical techniques including laparoscopic myomectomy, and hysteroscopic myomectomy, and MRI Guided Focused Ultrasound Surgery.
Other techniques, include uterine artery embolization (also called uterine fibroid embolization) and myolysis, can shrink the fibroids without actually removing them.
Finally, endometrial ablation can be effective to treat excessive bleeding from submucosal fibroids in women who do not wish to have children.
Major abdominal surgery, either to remove fibroids (abdominal myomectomy) or to remove the entire uterus (hysterectomy), is no longer necessary in the majority of cases
Cramps during periods (Dysmenorrhea)Dysmenorrhea means painful cramps during your period. Cramps are very common and can occur at any age, but severe cramps tend to occur more often in the late teens and early twenties. This type of abdominal pain usually begins when your period begins and peaks during the first day or two, when flow is heaviest. Some women also experience nausea, diarrhea or vomiting, fatigue, fever, headache, lower back pain and/or lightheadedness. In about 10% of women, cramps are so painful that they interfere with normal activities and prevent a woman from going to work or school.
Dysmenorrhea results from the release of chemicals called prostaglandins from the uterine lining cells. These chemicals cause contractions of the muscle wall of the uterus, which are felt as menstrual cramps. Women with severe dysmenorrhea tend to produce higher levels of prostaglandins.
Since a number of conditions can cause severe pelvic pain, it is a good idea to have a pelvic examination by your doctor to rule out other possible causes. Once you know there is no abnormality, your can treat your cramps with an over-the-counter nonsteroidal anti-inflammatory drug (NSAIDS) . NSAIDS work by blocking the formation of prostaglandins in the uterine lining cells; therefore, they work best if you take them just before your period or at the very onset of bleeding.
Birth control pills can help prevent painful periods because they tend to make the uterine lining cells thinner. This not only causes periods to be lighter and shorter, but also less painful since there are fewer cells to release prostaglandins.
Surgery is not recommended as a treatment for dysmenorrhea except in rare cases where pain is severe and unmitigated by other treatments. In such cases, your doctor may discuss the option of presacral neurectomy with you.
Chronic Pelvic Pain
Chronic pelvic pain is described as abdominal pain that is not associated with menstrual cramps occurring six months or more. Approximately 15-20% of women experience chronic pelvic pain. Often the cause is undiagnosed or misdiagnosed.
Chronic pelvic pain can have many different underlying causes, and not all of them are gynecological. Interestingly, the nerves that signal "pain" from the pelvic organs to the brain are all bundled closely together as they enter the spinal cord. Thus, the brain cannot always distinguish an exact location of the pain. It could be coming from the uterus, the fallopian tubes or the ovaries, or it could be coming from the bladder, the intestines or the internal abdominal muscles. For this reason it is sometimes difficult to determine the underlying cause of chronic pelvic pain. Sometimes a team of specialists that includes a gynecologist, a urologist, a gastroenterologist and a physical therapist may be needed to pinpoint the root of pain.
Gynecologic causes of chronic pelvic pain include adhesions (scar tissue), endometriosis, previous damage due to surgery or infections, and interstitial cystitis (IC) pelvic congestion syndrome.
In contrast, pain caused by ovarian cysts and ectopic pregnancies is usually acute (sudden and piercing).
One of the best means of identifying the cause of chronic pelvic pain is laparoscopy, a technique that allows the physician to view the pelvic organs including the uterus, fallopian tubes, ovaries, intestines, appendix, gallbladder and liver. This firsthand visual inspection can uncover problems such as endometriosis, pelvic infection, adhesions, ovarian cysts and ectopic pregnancies, as well as inflammation or infection of the appendix, intestines or gallbladder. Once the cause is known, an appropriate treatment can be determined.
Abnormal Uterine BleedingWomen vary greatly in their menstrual cycles: what is normal for one may be abnormal for another. Adolescents in particular may have tremendous variability in their cycles until their hormone levels balance out after several years of menstruation. Doctors define abnormal uterine bleeding as:
- Having a period less often than every 35 days.
- Having a period more often than every 21 days .
- Bleeding or spotting between periods .
- Bleeding very heavily (menorrhagia), that is, saturating a pad or tampon hourly for more than several hours
Causes of Abnormal Bleeding
Many lifestyle factors can disrupt your normal cycle and cause you to miss periods. These include stress, being overweight, losing weight too quickly, excessive exercise, and taking certain medications. Additionally, an abnormality of the thyroid gland or other hormonal imbalances may cause less frequent periods. All of these can be addressed by correcting the underlying problem, and in some cases through treatment with hormones.
On the other hand, very heavy abnormal bleeding may have a medical cause, such as:
- Ovarian cysts
- Von Willebrand's disease
The treatment your doctor recommends will depend upon the cause of your abnormal bleeding. If the cause is related to missed ovulation or an ovarian cyst, very often it can be treated simply with birth control pills. These provide regular and consistent amounts of estrogen and/or medication that acts like progesterone to the body and help regulate your monthly cycles.
Another option is a new type of intrauterine device (IUD) that releases small amounts of a progesterone-like hormone continuously directly to the uterine lining cells. This has the effect of thinning the lining of the uterus and reducing menstrual blood flow by up to 80%.
Some over-the-counter anti-inflammatory medications such as ibuprofen and naproxen are effective in reducing bleeding by constricting the blood vessels.
Surgical options for most noncancerous gynecological conditions include a number of minimally invasive techniques that correct such problems as fibroids and polyps without causing undue disruption of one’s life and routine. These include laparoscopic surgery, D&C, endometrial ablation, hysteroscopy and focused ultrasound.
The appropriate treatment, of course, will depend on your medical condition as well as other factors - your age, whether or not you wish to have children, your state of health, the risks of recurrence, etc. - and should be discussed with your doctor. It is always a good idea to try the least invasive options before resorting to major surgery.
It is the medical name for very heavy menstrual bleeding (soaking through a sanitary pad or tampon every hour for more than a few hours) that lasts longer than seven days. It is a common form of abnormal uterine bleeding.
Abnormal uterine bleeding affects an estimated 30% of women at some point during their lives. Hormonal changes are often the cause in teenagers during the 1 to 1 ½ years following their first period, as well as in women in their 40s and 50s who are approaching menopause. In general, menorrhagia is more common among older women than among younger women. One study found that nearly 40% of women between the ages of 45 and 60 experienced abnormally heavy periods.
Besides hormonal changes, other causes of abnormal bleeding are fibroids, ovarian cysts, uterine or cervical polyps, and overgrowth of the uterine lining cells, called "hyperplasia." All of these can be easily and effectively treated. Very rarely, abnormal uterine bleeding signals precancer or cancer of the uterus.
Up to 15% of women who have menorrhagia may have an undiagnosed bleeding disorder called von Willebrand’s disease, an inherited condition in which the blood lacks certain factors needed for proper clotting. Von Willebrand’s disease may be likened to a very mild form of hemophilia and must be treated with the appropriate clotting factors. It is important to get a proper diagnosis of the cause of abnormal bleeding, because the treatments for menorrhagia will not work if the true cause is a bleeding disorder.
Abnormal uterine bleeding may be treated with hormones, medications, or minimally invasive surgical procedures.
In younger women, treatment with hormones almost always solves the problem. However, if bleeding persists after medical therapy has been tried, certain tests can be used to determine the cause. These include hysteroscopy, D&C, endometrial biopsy, sonogram and saline-infusion sonogram.
The appropriate treatment is determined by the underlying cause of the bleeding. If abnormal bleeding is due to fibroids, resectoscopic myomectomy may be appropriate. If it is due to polyps or hyperplasia, a D&C may correct the problem. In some women, abnormal bleeding may persist even after hormonal treatment, medical therapy or a D&C. Sometimes this is due to changes in the uterine muscle wall or the uterine lining. For those who do not wish to have children and for whom the abnormal bleeding is severe enough to cause anemia, a technique called endometrial ablation may be the right choice.
Hysterectomy should only be used as a last resort, after other approaches have failed, or when appropriate to eradicate uterine cancer.
It is important to discuss all treatment options with your doctor.
Urinary incontinence (UI), the involuntary leakage of urine from the bladder, affects some 25 million adults, 75-80% of them women. Estimates of the annual cost of managing and treating incontinence in the U.S range from $16 billion to $26 billion.
There are three principal types of incontinence:
- Stress urinary incontinence or SUI.
- Overactive bladder (also called urge incontinence).
- Mixed incontinence.
• STRESS URINARY INCONTINENCE
Stress urinary incontinence or SUI is the most common type of incontinence, characterized by leakage of urine during coughing, sneezing or laughing. SUI is caused by weakening of the pelvic muscles that support the bladder and urethra. As a result, the urethra is not held in its correct position and/or loses its seal. Then, when a sudden movement of the diaphragm puts pressure on the bladder, the sphincter muscle on the urethra is not able to control the leakage of urine. SUI may be a symptom of pelvic organ prolapse, but it is also a health condition on its own. Unlike other forms of incontinence, SUI is not accompanied by an urge to urinate.
Studies suggest that SUI may affect more than 30 million American women. Although SUI can occur in women of all ages, it becomes more prevalent with age. One review of published studies estimates that severe symptoms of SUI are experienced by:
- 29% of women aged 25 to 44 years
- 33% of women aged 45 to 60 years
- 86% of women aged 60 or older
The single biggest risk factor is vaginal childbirth. The risk of SUI increases proportionately with the number of vaginal deliveries a woman has had. Previous gynecologic surgery, especially a hysterectomy, is another factor: women who have had pelvic surgery have a 40% higher risk of developing SUI. Other risk factors include high-impact physical activity, smoking, and chronic conditions such as obesity, respiratory ailments, coughing and constipation.
SUI is not well known or understood by most women. According to the National Association for Continence, most women with SUI suffer from the condition for 3 to10 years before talking to their doctor about it. As many as two-thirds of women with SUI never talk about it with their doctors at all. This is a serious concern, because SUI has a negative impact on a woman’s quality of life, self-esteem and activity level. In one survey, nearly 60% of women with SUI said they changed their lifestyle to accommodate their condition instead of seeking medical help.
It is important for women to know that incontinence is not a normal consequence of aging. In addition to non-surgical approaches, minimally invasive surgical approaches are now available to treat SUI, so women do not have to accept a compromised lifestyle. These include retropubic suspension and sling procedures performed vaginally such as TVT.
• OVERACTIVE BLADDER/URGE INCONTINENCE
Overactive bladder (OAB) and urge incontinence (UI) are overlapping conditions characterized by the sudden, uncontrollable urge to urinate about every two hours, including through the night. UI occurs when nerve passages along the pathway from the bladder to the brain are damaged, causing a sudden bladder contraction that cannot be consciously inhibited. Many factors can cause overactive bladder, including certain types of foods, beverages and medications. However, some cases of OAB have no known cause.
According to the National Association for Continence, about 17% of women and 16% men over 18 years old have overactive bladder and an estimated 12.2 million adults have urge incontinence. Like SUI, OAB and UI occur more frequently in women than in men and become more prevalent with age. Women with OAB are significantly more likely to suffer from other health disorders, such as hypertension, obesity and arthritis, than women without OAB.
OAB has a negative impact on a woman’s quality of life. In a national survey, sufferers of OAB reported they are two to three times more likely to regularly experience disturbed sleep, overeating and poor self-esteem, compared with non-OAB sufferers.
At least 80% of people with urinary incontinence can be cured or improved. Treatment of OAB/UI normally involves lifestyle changes and techniques for bladder retraining, strengthening of pelvic floor muscles, and frequently medications.
• MIXED INCONTINENCE
Mixed Incontinence is the coexistence of both stress urinary incontinence and overactive bladder/urge incontinence. It affects approximately one-third of all women with SUI. Treatment options are likely to include approaches for both conditions and will depend on which symptoms are most troublesome to the patient.
An ovarian cyst is a collection of excess fluid in the ovary. The formation of fluid around a developing egg is a normal process in all ovulating women, but sometimes, for reasons doctors do not yet understand, too much fluid is formed. The follicle containing the egg expands, forcing the ovary to expand as well, and this may be experienced as pressure or pain in the pelvic area. On the other hand, some women do not feel the cyst at all, and it may only be discovered during a routine gynecological exam.
The vast majority of ovarian cysts are not cancerous, and most of the time they go away by themselves as the fluid is absorbed back into the body. The formation of new cysts can often be prevented by taking birth control pills.
When do cysts need to be removed?
Rarely, a cyst may not go away and surgery may be needed to remove the cyst.
One scenario is that the cyst causes the ovary to twist around, cutting the blood flow to the ovary and causing severe pain. This is called ovarian torsion.
Another reason for surgery is the presence of an epithelial ovarian cyst. During ovulation the ovary releases an egg through a tiny rupture in its lining, or epithelium. Normally this closes and heals quickly without incident. Sometimes, however, a few cells from the epithelium make their way into the divot left by the egg and become trapped there during healing. These cells form a fluid that collects and grows into an epithelial ovarian cyst. Because the cyst is trapped inside the ovary, it must be removed surgically.
A condition called endometriosis can cause a blood-filled ovarian cyst called an endometrioma that will require surgical removal. This type of cyst is formed from endometrial cells (cells from the inner lining of the uterus) that mistakenly traveled up through the fallopian tube into the ovary and began to grow there. Endometrial cells are programmed to grow and bleed with the monthly cycle, and normally they are shed with the menstrual flow. However, if they become trapped inside an ovary, the blood collects and forms a cyst.
Some ovarian cancers are cystic, so that persistence or increased growth of a cyst as viewed on a sonogram warrants laparoscopic investigation with removal of the cystic tissue for histologic inspection and diagnosis.
Cysts which are partially solid or have internal wells as determined by ultrasound may also have to be removed.
Since most ovarian cysts in premenopausal women disappear spontaneously, treatment is seldom required. Women who are prone to developing cysts repeatedly may want to use birth control pills to prevent the growth of new cysts until they are ready to bear children.
For cysts that do need to be removed, minimally invasive laparoscopic surgical techniques can now be used to remove these cysts (cystectomy) while preserving the health of the ovary and promising a quick recovery
Overgrowth of the uterine lining (hyperplasia)
Hyperplasia or overgrowth of the uterine lining is an accumulation of uterine lining cells that can occur when periods are infrequent or too light. The condition is also known as endometrial hyperplasia, because the technical word for the lining of the uterus is endometrium.
In the normal female reproductive cycle, the lining of the uterus is shed monthly during menstruation in response to signals the brain receives from hormones in the bloodstream. At the beginning of the cycle, the ovaries produce estrogen. Estrogen encourages the lining of the uterus to grow in preparation to receive a fertilized egg. After ovulation, the ovary begins to release the hormone progesterone, which signals the lining cells to secrete nutrients. If the egg is not fertilized, the ovary stops producing both hormones after about two weeks. Without these hormones, the uterine lining cells die and are shed during menstruation, and then the cycle begins again.
Many factors can cause hormonal imbalances that interfere with this cycle temporarily. Lack of ovulation due to stress, rapid weight loss, excessive exercise or ovarian cysts may interrupt the cycle, because without ovulation, progesterone is not produced and bleeding will not occur. If this goes on for many months, overgrowth of the uterine lining cells may result.
Too much estrogen in the bloodstream can stimulate overgrowth of uterine lining cells. This can happen in women who are overweight, because fat cells produce estrogen. A high level of estrogen (not counterbalanced by progesterone) tells the body not to shed the uterine lining. If this is perpetual, eventually there will be an overgrowth of uterine lining cells.
Hyperplasia in itself is not a serious condition and can be corrected with hormone therapy. Atypical hyperplasia, however, is an overgrowth of cells that may turn into cancer, and this condition involves different treatment.
Pelvic Congestion Syndrome
Pelvic congestion syndrome is a condition in which the veins in the pelvis become stretched, widened, and congested with blood, similar to varicose veins in the legs. It occurs when the valves that control blood flow to the heart leak, allowing the blood to flow backward and pool in the pelvic veins. The organs affected are the uterus, ovaries and vulva.
Pelvic congestion syndrome occurs most often in women who have borne children. It may affect up to 15% of women in their reproductive years and is increasingly being recognized as a cause of chronic pelvic pain, particularly pelvic pain that cannot be attributed to other causes. Women with pelvic congestion syndrome feel a dull, aching pain in the abdominal area, lower back and sometimes the legs. The pain gets worse at the end of the day or after standing for long periods of time. Other symptoms may include vaginal discharge, urinary frequency, and pain during sexual intercourse.
Ovarian dysfunction is suspected as a cause, because pelvic congestion syndrome was resolved in patients whose ovaries were removed. Also, it has been found that more than half of women with pelvic congestion syndrome have ovarian cysts, dysmenorrhea or irregular periods. Estrogen is a culprit in causing pelvic congestion syndrome because it stimulates the pelvic veins to dilate. In a study that suppressed the release of estrogen from the ovaries, pain was reduced.
Pelvic congestion syndrome is diagnosed with ultrasound or laparoscopy. In some cases, medication that constricts the blood vessels or suppresses ovarian function can help relieve the pain. A nonsurgical procedure called ovarian vein embolization has a good track record in alleviating pain in the vast majority of patients. Recently, the use of laparoscopic surgery to clip the damaged veins was also shown eliminate pain. In very severe cases, oophorectomy and hysterectomy may be considered as a last resort.
Pelvic inflammatory disease
Pelvic inflammatory disease or PID is an infection of the uterus, fallopian tubes and/or ovaries caused by migration of bacteria usually acquired from sexually transmitted diseases (STDs), particularly gonorrhea and chlamydia. It can lead to infertility, ectopic pregnancy, chronic pelvic pain or other serious consequences. PID is common among sexually active women; an estimated one million American women and teens experience an episode of PID each year. It causes infertility in about 100,000 women annually, as well as a significant percentage of ectopic pregnancies as a result of damage to the lining of the tube.
Besides STDs, other contributing factors may be douching (which can flush bacteria from the vagina up into the uterus, fallopian tubes and ovaries). There is no evidence that it is caused by IUD.
Symptoms include pelvic pain and abnormal vaginal discharge, which may be accompanied by fever, irregular periods, pain during intercourse or pain during a pelvic exam.
PID is usually diagnosed through a pelvic exam and tests for STDs. Recurrent PID may be diagnosed by laparoscopy. It can be treated with antibiotics, but the damage it has caused is permanent. The best strategy is prevention through using condoms, abstaining from sex or limiting your number of sexual partners, having regular screenings for STDs, and seeking prompt medical attention at the first sign of infection.
Polyps (Uterine Polyps)
Uterine polyps are small, benign protrusions of tissue that grow on the uterine lining ( endometrium). They are overgrowths of the same kind of cells as the lining itself and may appear as finger-like projections or little mushrooms. As they grow, they become fragile and bleed, and as such, they are a common cause of abnormal uterine bleeding.
Uterine polyps are usually diagnosed using an instrument called a hysteroscope, a slender telescopic device that provides the physician a magnified view of the uterine cavity, but can also be diagnosed with a sonogram.
Occasionally a polyp may grow on or through the cervix and cause irritation and irregular bleeding. This type of polyp can be seen during a pelvic examination when the doctor examines the cervix through a speculum.
Are polyps a sign of precancer?
In other tissues, such as the colon, polyps have long been considered an "early warning sign" of cancer; in contrast, uterine polyps have been thought to be generally benign. However, with the increased use of pelvic sonograms, more polyps are now being detected, and a recent study found that the rate of polyps with abnormal cells was nearly 16% among women who opted to have them removed. In 2% of the women, endometrial cancer was found. The authors of the study recommend that women with polyps should be encouraged to have them removed, given the high rate of abnormal pathology and the relative ease of treatment.
Removal of polyps, called polypectomy, can be done under a local anesthetic in an outpatient setting. Polyps can also be removed by operative hysteroscopy.
Pelvic organ prolapse
Pelvic organ prolapse or POP is a condition in which one or more of the organs in your pelvic cavity -- uterus, vagina, bladder and rectum - has fallen below its natural position in the pelvis. These organs are normally held in place by a web of muscles and connective tissues that act like a hammock. However, when these muscles and tissues become weakened or damaged, one or more of the pelvic organs shift out of normal position and literally "fall" into the vagina.
Pelvic muscles may be weakened or stretched by giving birth vaginally, especially if you had a difficult labor and delivery, multiple vaginal deliveries and/or large babies. Being overweight, loss of muscle tone with aging, or having a hysterectomy or other abdominal surgery are additional reasons why these muscles may be weakened.
- The risk of prolapse increases nearly 20 percent with each additional vaginal delivery up to five births.
Heredity may play a role in determining who is predisposed toward POP and who is not, because statistics suggest that POP occurs more often in women of Northern European and Hispanic descent than in women of African or Asian descent.
Few studies have been conducted to find out how many women have experienced POP.
Despite the fact that POP is a relatively common condition, affecting at least half of all women who have had children, it is believed to be under reported, under diagnosed and under treated. Many women are embarrassed to discuss their symptoms with their physician, and physicians themselves rarely raise the topic with their patients. There is a general lack of education about POP: 4 out of 5 women have never even heard of it. When they have, it is most often from their mother or other family member. Historically, women were told POP is a fact of aging they just have to accept.
There are many degrees of prolapse. Women with very mild cases may have no symptoms at all. In fact, an estimated 80-90% of women with mild prolapse are asymptomatic. Women who have mild to moderate degrees of prolapse may experience a feeling of pressure or heaviness in the pelvic area after being on their feet for a long time or after physical exercise. In more severe cases, prolapse has an impact on a woman’s quality of life through such symptoms as:
- Difficulty in completely emptying the bladder.
- Bowel problems are not common.
- Pain or discomfort during intercourse.
- Pressure or pain in the pelvic area and lower back.
- Urinary incontinence, in which urine is leaked during activities such as laughing, coughing or exercising
a bulge or lump in the vagina.
- A feeling that something is falling out of the vagina, like a tampon that is half in and half out
To diagnose POP your health care professional will take a detailed medical history, then perform a pelvic exam to determine the kind and degree of POP you have. A standing exam is best, because the weight of your organs will push down and make it easier to assess the prolapse.
There are several different types of POP.
- In uterine prolapse, the uterus drops down into the vagina. This has been happening to women since humankind began and was one of the first gynecological conditions to be described. It used to be called "falling of the womb," and in earlier times women felt they just had to live with it. Today, however, excellent treatment options exist.
- Women who have had a hysterectomy can develop vaginal vault prolapse, where the top of the vagina protrudes into the lower vagina.
- A cystocele is prolapse of the bladder into the front vaginal wall.
- A rectocele is prolapse of the rectum, pressing into the back vaginal wall.
- An enterocele is protrusion of the small bowel pressing against the front of the vagina.
It is possible to have more than one type of prolapse at the same time. Your doctor will measure the position of your uterus and other organs to determine the degree of prolapse and will discuss various treatment options with you.
A variety of POP treatments are available, both non-surgical and surgical. The right choice for a particular woman will depend on the type and degree of prolapse, the symptoms she is experiencing, and other general medical factors.
Many women with mild to moderate symptoms respond well to non-surgical approaches. For a woman who feels her condition impairs her quality of life, pelvic repair surgery may be a good choice. Today, minimally invasive techniques can correct the problem without the lengthy recovery, pain and increased risk of infection that are associated with open abdominal surgery. Some gynecologists specialize in "pelvic floor" repair
Adhesions are bands of scar tissue that form during healing from pelvic surgery, infection or endometriosis. Although the formation of scar tissue is a normal part of the healing process, adhesions can be problematic because they cause parts of the body that are not normally connected to stick to each other. For example, the intestine may become connected by adhesions to the uterus, or the fallopian tube may stick to the ovary. Scar tissue is very tough and lacks the flexibility and elasticity of normal tissue. Thus, adhesions impair the normal movement of the pelvic organs and can cause pain.
The formation of adhesions in women who have gynecologic surgery is very common; in fact, 90% of all women who undergo gynecologic surgery are at risk for forming adhesions. Adhesions do not always cause pain or other problems. However, in some cases they can be a complication requiring further surgery.
When adhesions form inside the uterus (intrauterine adhesions), they can interfere with normal periods, fertility or pregnancy. In women who have had endometrial ablation, intrauterine adhesions may mask or obstruct bleeding from any endometrial tissue that remains or regenerates, and this may cause pain and other problems. When adhesions form between the uterus and the intestine, they can lead to bowel obstruction.
The risk of forming adhesions can be reduced with the use of materials that have been developed to prevent adjacent tissues from sticking to each other. One type is a cloth like material and the other is a gel; both dissolve after a few weeks.
Additionally, some evidence suggests that adhesion formation is reduced when surgery is performed laparoscopically.
When adhesions are severe and painful or cause other health problems, they can be removed surgically. In the past this was done using open abdominal surgery, but today it is more often done using laparoscopic surgery because of the reduced trauma to the body.
Tubal Pregnancy (Ectopic Pregnancy)
An ectopic pregnancy, also called a tubal pregnancy, occurs when a fertilized egg fails to make its full journey into the uterus and, instead, implants itself in the fallopian tube and begins to grow there. and begins to grow there. The fallopian tube cannot support a pregnancy. As the developing fetus grows, it stretches and then tears the fallopian tube, causing pain. At the same time, the placenta cannot develop properly, and the uterine lining cells are deprived of the pregnancy hormones they need. These cells break down, causing bleeding. Thus, if you think you are pregnant, pain and bleeding are warning signals of an ectopic pregnancy and you should see your doctor immediately.
The fallopian tube may be blocked by scar tissue from an infection such as pelvic inflammatory disease, by endometriosis, or by unknown other factors.
Ectopic pregnancy can now be diagnosed very early, before it tears the fallopian tube, by measuring the levels of a pregnancy hormone called beta HCG in your blood. If HCG levels are elevated, the pregnancy should be visible on a sonogram. If it is not, an ectopic pregnancy is probable.
An early ectopic pregnancy can be treated with a drug, methotrexate, which destroys the pregnancy tissue in the fallopian tube.
In some cases, laparoscopic surgery may be needed to remove the pregnancy tissue from the fallopian tube.
The lining tissue of the uterus is called the endometrium. Each month (except during pregnancy) this lining is shed through the cervix and into the vagina during the menstrual period. However, some of the blood and lining cells may exit the uterus in the wrong direction, flowing up through the fallopian tubes and into the abdominal cavity. This is sometimes called retrograde bleeding. It is a fairly common occurrence, but usually the body's immune system recognizes that these cells are in the wrong place and eliminates them.
For unknown reasons, in some women these uterine lining cells may grow outside the uterus. They may grow in or on the ovaries, in the fallopian tubes, on the outer surface of the uterus, or on other areas of the membrane that lines the abdominal cavity. The cells still behave like uterine lining cells, however – growing full of blood and nutrients in preparation to receive an egg and bleeding afterwards as in normal menstruation. This condition is called endometriosis. The blood and other biochemicals released by the endometriosis cells begin to irritate the surrounding tissues, causing pelvic pain. Eventually the body may form scar tissue around these injuries, which can lead to more pain.
Endometriosis is a common gynecological condition among American women of all ages, races and backgrounds. It is more common in women in their 20’s and 30’s, but even adolescents can develop endometriosis. Because endometriosis responds to the monthly release of female hormones (estrogen and progesterone), it decreases and eventually disappears with menopause.
Although the exact cause or causes are not understood, there seems to be a genetic component. A woman whose mother or sister has had surgically proven endometriosis has a sevenfold higher risk of developing the condition than women in the general population.
In addition to causing pelvic pain, endometriosis can affect fertility. Mild cases can reduce the chance of getting pregnant from the normal 25% per month to around 7% per month, for a healthy woman in her 20s. More extensive endometriosis that involves scarring, blocking of the fallopian tubes or large cysts in the ovaries (endometriomas) reduce these chances further.
When a woman complains of chronic pelvic pain, pain with sex, low back pain, painful bowel movements or sudden, knifelike pelvic pain, her physician may suspect endometriosis. Sometimes it can be felt during the rectal part of a pelvic examination as tender, thickened areas near the uterus. A sonogram can reveal the presence of an ovarian cyst and may show patterns characteristic of endometriosis. However, the only way to obtain a definite diagnosis is with visual inspection of the organs, which is done by laparoscopy.
Both medical and surgical approaches are available to treat endometriosis, and both have had good success rates at reducing pain and improving fertility. If surgery is required, endometriosis can usually be treated with laparoscopic surgery.