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Creation is inevitably banded with care. It is through care that creation becomes complete Life. It’s precious. Maintain a healthy life by knowing your body. Please refer any of the following article by selecting the respective links. Looking after you body is one of the many ways to respect creation and honour life.
  • Bone Pains
  • Excessive Uterine Bleeding
  • Fibroids
  • Hysterectomy
  • Infertility
  • Menopause
  • Normal Pregnancy
  • Ovarian Cysts
  • Urinary Problem

Osteoporosis
Dr.Shobhana Mohandas.MD., DGO., FICOG.Dip Endoscopy
Sun Medical and Research Centre, Thrissur, Kerala


What is osteoporosis?
Osteoporosis is the thinning of bone tissue and loss of bone density over time. In osteoporosis the bone mineral density (BMD) is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered. Osteoporosis occurs when there is an imbalance between new bone formation and old bone resorption. Two essential minerals for normal bone formation are calcium and phosphate. After menopause sets in, oestrogen levels fall , and this leads to osteoporosis. Decreased dietary intake of calcium lack of weight bearing exercise, also contribute to the setting in of osteoporosis.

What are the symptoms of osteoporosis?
Osteoporosis is a silent disease. It may not cause any symptoms till there are minute fractures called fragility fractures, which commonly occur in vertebra, rib, wrist, and hip. Multiple vertebral fractures lead to a stooped posture, loss of height, and chronic pain with resultant reduction in mobility in the elderly. If there is loss of more than 1.5 inches then it means already there are micro-fractures in the spine. This hump is because of weak extensor muscles of the back along with very small fractures of the upper backbone which go unnoticed most of the time and are not diagnosed in more than one-third cases. This interferes with the quality of women's life by causing chronic backache, decreased chest space resulting in respiratory problems and decreased abdominal space leading to poor digestion.

How can one prevent osteoporosis?
Doing weight bearing exercises for about half an hour per day after theage of 35 is a good way of keeping osteoporosis away. Taking calcium rich food like milk or milk products, green leafy vegetables, and legumes,can aslo prevent osteoporosis. Calcium excretion is enhanced with intake of tea or coffee and one should cut down on their consumption.

How is it possible to know if one’s bones are weak?
Answer: Weakening of bones caused by osteoporosis is a silent disease. One need not wait till one gets physical symptoms to know if the bones are weak. Periodic testing of the bones with special tests like DEXA or ultrasound of the heel bone can detect if the bones are beginning to get holes in them. This will warrant the use of medications, a little more than the ones used for prevention of bone pains.

I am 42 years old. I get low back ache when I try to work for long periods of time. How can I get rid of this problem?
ow back in the 40 plus woman could be due to lumbar strain. A lumbar strain is a stretch injury to the ligaments, tendons, and/or muscles of the low back. The stretching incident results in microscopic tears of varying degrees in these tissues. The condition is characterized by localized discomfort in the low back area with onset after an event that mechanically stressed the lumbar tissues. The treatment of lumbar strain consists of resting the back (to avoid re-injury), medications to relieve pain and muscle spasm, local heat applications, massage, and eventual (after the acute episode resolves) reconditioning exercises to strengthen the low back and abdominal muscles. Resting the back should not go on for too long, as this can also be bad for your back.

Other causes of back ache could be bony projections hitting the spinal nerves or degenerative conditions of the bones or joints of the back. Correct diagnosis can be evolved with investigations.
Conditions affecting the uterus or ovaries can also rarely cause backache, and this should be ruled out, but in majority of cases, back ache is caused by abnormalities caused in the back itself. If the source of the pain lies in the reproductive organs, other problems often occur as well, including a sensation of pressure on the bladder, urinary urgency, and pain during urination, defecation or sexual intercourse

I had undergone hysterectomy for fibroid uterus . The doctor did not remove my ovaries. However, now I get severe pain in my knees . Is it related to hysterectomy or menopause?
Answer: Hysterectomy or menopause cannot cause pain in the knees. Pain in the knees could be caused due to inflammation in the kneejoint, injury to muscles or ligaments around the knees, or even degeneration of the bones near the knee joints, called osteoarthritis. None of these conditions are caused by menopause. It is a misconception to think that hysterectomy can lead to many aches and pains.
It is commonly known that after menopause, bones become weak. This is because, the hormone oestrogen is not there to hold the mineral calcium in the bones, and this leads to the bones becoming porous. However, this phenomenon is most commonly seen in the hips, back and wrists.
I have undergone hysterectomy with removal of both ovaries. I am 40 years old. Should I take any suppliments to prevent backache? I have heard that menopause leads to weakening of bones.
Your ovaries still had a few ova in them which would have protected your bones for some more time, besides many other functions. Since your disease needed removal of this protection, it would be good for you to take hormone replacement therapy till you are 45- 50 years of age. This will also prevent weakening of bones. Life style changes should be made , as written in the answer to the previous question.

Q2. I have undergone hysterectomy and my ovaries are intact. Should I take treatments like calcium suppliments or some other drugs ?
If the ovaries have not been removed, they will continue to produce hormones if you are at an age when they still function. They will stop functioning after some time when the number of ova in the ovaries gets depleted with age. Till such a time, there is no need to take supplements, just because one has undergone hysterectomy. You must remember to find time to walk for at least 20 minutes a day, avoid easily digestible sugars, take adequate amount of vegetables and fruits, and make sure you take at least a glass of milk or curd or buttermilk, so you have some amount of dietary calcium. After the age of 50, oestrogen will stop protecting the bone, so it will be good if you can take calcium tablets regulary, as the body’s need for calcium increases, ( 1200-1500mg/day is the requirement after 50 years)and this much calcium cannot be provided by the average Indian diet, which gives only about 600-800 mg of calcium per day.

Q3. I have undergone hysterectomy with removal of both ovaries. I am 40 years old. Should I take any suppliments to prevent backache? I have heard that menopause leads to weakening of bones.
Your ovaries still had a few ova in them which would have protected your bones for some more time, besides many other functions. Since your disease needed removal of this protection, it would be good for you to take hormone replacement therapy till you are 45- 50 years of age. This will also prevent weakening of bones. Life style changes should be made , as written in the answer to the previous question.


Questions and Answers compiled by
Dr.Shobhana Mohandas. MD.DGO.FICOG.Dip.Endoscopy.
Consultant Gynaecologist, Sun Medical and Research Centre,
Thrissur, Kerala.
Email: shobhanamohandas@yahoo.co.in.

Abnormal Uterine Bleeding
Dr.Shobhana Mohandas.MD.DGO.FICOG. Dip.Endoscopy
Sun Medical and Research Centre, Thrissur, Kerala.


Menstruation is a normal physiological event occurring in a woman in the reproductive years. Normal menstruation occurring in normal quantity is reassuring to the woman, in spite of the small inconveniences experienced during the period. Any change from the normal pattern gives rise to anxious moments. The reasons for abnormal bleeding varies according to the age of the patient. In the years following the first menarche and in the years preceding menopause, there may be disorders of ovulation. Ovulation is the normal process of extrusion of ova in women). In the reproductive years, bleeding may occur in spite of normal ovulation. Besides these hormonal abnormalities, tumours in the uterus or ovaries could cause excessive or irregular uterine bleeding.

In the following section, a few of the commonly faced situations are discussed.
Q:What is normal menstruation?
A: Normal menstruation means menstruation occurring once in 28-35 days, the flow being moderate in amount for the first 2-3 days and petering out to a complete stop in 7 days time.

Case example:A young 12 year old girl who has attained menarche (first menstruation) 6 months back comes with bleeding coming on every 15 days. The flow is not heavy, but it is bothersome and the girl is not able to concentrate in her studies. Does it need medical intervention?
A: Menstruation is a result of the combined efforts of the uterus, the ovaries and the brain. In the first few years after mernarche, menstruation tends to be a bit irregular, because the body systems are yet to mature. In due course of time it may mature and regular menstruation may ensue. Meanwhile there may be signs of anaemia like inability to concentrate, etc. Taking iron tablets with a good nutritious diet will help in tiding over the situation. If the menstruation still does not become normal, taking oral contraceptive pills for 3 months will help. As the flow is not very heavy, probably detailed investigations could be deferred.

Case example:If the same girl comes with heavy bleeding, what could be the reason?
A: If the bleeding is heavy, then the girl should be evaluated thoroughly. An ultrasonography should be done to rule out any abnormalities in the uterus or ovaries. A detailed blood test should be done to rule out any bleeding disorders or abnormalities in the blood cells. If there are any abnormalities detected, treatment should be given to cure the disease. If every thing is normal, she may need treatment with heavy doses of hormone pills.

Q: If a woman in the reproductive age group comes with heavy bleeding what could be the reason?
A: In the reproductive group the causes could be
  • Pregnancy related problems.
  • Intrauterine device related problems
  • Hormonal imbalance.
  • Ovarian cysts or uterine fibroids.
  • Pelvic inflammatory disease.


Pregnancy related problems:In a woman in the reproductive age group, unintentional pregnancy and related problems should always be kept in mind. It is commonly believed that pregnancy will occur only if a woman misses her periods. But it is quite possible that even without missing her periods, a woman may be harbouring an abnormal pregnancy either in the uterus or even outside the uterus, which is then called an ectopic pregnancy. Ectopic pregnancies are usually associated with pain in the abdomen.

Intrauterine device related problems.
Patients using copper containing intrauterine contraceptive devices could have bleeding related to a foreign body reaction to the device. Usually the first 2-3 months following insertion of the IUD is associated with irregular and excessive periods, but it settles on its own. If it is excessively heavy even after that, medical intervention may be necessary.

As in all age groups, abnormal tumours in the uterus or ovaries should be ruled out.
Any infections in the uterus or nearby structures (Pelvic inflammatory disease) could also cause abnormal bleeding. Clinical examination can rule out gross abnormalities. Ultrasonography is a more accurate method of ruling out abnormalities in the pelvic organs. In women with no structural or pregnancy related abnormalities, any bleeding is called dysfunctional uterine bleeding. While in the post menarchal or premenopausal women, these abnormalities occur due to disorders in ovulation, in women in the reproductive age group, bleeding occurs in spite of normal ovulation. Quite often they can be cured by non-hormonal medical treatments.

Q:What are the abnormalities in menstruation are expected in the woman nearing menopause?
The menstrual irregularity at perimenopause is the result of physiologic reduction or depletion of healthy oocytes (ovarian eggs). The remaining oocytes of the ovary are of lesser competence and cannot sustain the normal hormone balance. In most women this menstrual dysfunction continues till menopause (complete cessation of menses). In the perimenopause period, the previously regular periods tend to become irregular with changes in intermenstrual lengths. The perimenopause is divided into two phases:

• Early perimenopause – The menstrual cycles may be short or prolonged.
• Late perimenopause – Characterized by lengthened intermenstrual periods, resulting in prolonged and irregular menstrual cycles. In some women, the menstrual bleeding may be prolonged and heavy requiring immediate medical attention.

Q: What are the factors in menopause that cause and aggravate abnormal bleeding during menstruation?
The normal cyclic periods are the result of normal balance between estrogen and progesterone (ovarian hormones). In the perimenopause, disruption of normal hormonal sequence results in erratic response of the endometrium (inner lining of uterine cavity). In most p e r i m e n o p a u s a l women ovary is the major source of estrogen production. However, in obese women the excess of adipose (fat) tissue also produces high amount of estrogen. The unopposed estrogen action can cause excessive thickening of endometrium resulting into irregular and heavy bleeding. Some of the changes in the endometrium may have malignant potential. Other Structural changes like uterine fibroids, polyps, adenomyosis, ovarian tumours and pelvic infections can also cause irregular and heavy menstrual bleeding.

Q: What are the types of bleeding that occur in perimenopause?
The menstrual dysfunctions at perimenopause are of different types:

  • Regular periods with excessive cyclic bleeding
  • Short menstrual periods with normal or excessive bleeding
  • Infrequent and delayed periods with normal or excessive and prolonged bleeding
  • Irregular and non-cyclic prolonged periods with scanty or excessive bleeding

Q:What are the treatment options for dysfunctional uterine bleeding in women who have completed child bearing?
In the woman nearing menopause, one has to rule out cancer of the lining of the uterus, called the endometrium. This is done by Ultrasonography in the early menstrual period, or by sampling the endometrium and sending it to a pathologist. Sampling the endometrium can be done by using a device called the Endometrial pipelle, as a day care procdure. It is a fairly painless procedure, where a thin hollow plastic device is passed into the uterus and small pieces of endometrium taken out to look for signs of malignancy. Once this has been done, drugs are given to control the bleeding. Hormone preparations and non hormone preparations are used by doctors depending on the case, to control this situation. Sometimes, quick and permanent response to medical treatment is also an indication of the bleeding being benign in nature. Associated medical disorders like thyroid dysfunction, diabetes mellitus, pelvic infections should be ruled out. Iron-deficiency, anemia is a very common nutritional disorder in Indian women and menstrual dysfunction further aggravates this deficiency. Therefore, this needs to be treated simultaneously.

What are the other treatment options for women who continue to have abnormal bleeding?
1.D&C: In women who have completed childbearing, when medical treatment fails, a small procedure called D&C (Dilatation and curettage) may be done. It involves widening the opening of the uterus and putting in a curette and scraping the inner surface of the uterus. This inner lining of the uterus is called the endometrium. The endometrium which is thus taken out is submitted for testing in a pathological laboratory to make sure there is no malignancy in it. This procedure besides being diagnostic to rule out malignancy may also be curative. Bleeding may completely stop after this. D&C is usually done as a day care procedure and need not involve admission to the hospital. However, hysteroscopic evaluation of the uterus is superior to Dand C , but not many patients can avail of this facilty, so Dand C continues to be practiced.

2.Medicated intrauterine devices: Intra-uterine devices medicated with a hormone called progesterone are placed in the uterus. The advantage of this IUD is that it is a simple procedure and avoids the complications of surgical procedures. The disadvantage is that it is a bit costly (Around Rs.7500). Although the cost may seem to be a bit high for the average patient, it is certainly worth trying specially in cases where surgery or anaesthesia poses a risk to the patient. In India, it is marketed by the name MIRENA.

3.Endometrial Ablation: In dysfunctional uterine bleeding the irregular or excessive and prolonged bleeding is caused by irregular shedding of the inner lining of the uterus called the endometrium. This lining can be destroyed using many modalities like heat, electricity, laser, microwaves etc. These procedures could be a boon to the woman with DUB with risk of surgery or anaesthesia.

4.Thermal ablation: A rubber device is introduced into the uterus and a hot solution is passed into the rubber balloon. The heat of the solution is transmitted across the rubber balloon on to the lining of the uterus which is desiccated. . Most of them attain normal menstruation or decreased menstruation. Very few attain stoppage of menstruation. It is done as a day-care procedure and can be done under local anaesthesia and sedation or under mild general anaesthesia. Immediately following the procedure there may be uterine cramps which settles with antispasmodics. Some women may have profuse watery discharge for a month or so.

5. Hysteroscopy: An instrument called hysteroscope is inserted into the uterus, The uterus is distended with fluid. Any small projections into the uterus called polyps can be removed using special equipments called resectoscopes. The endometrium can also be ablated using this instrument.

6. Hysterectomy: If medical treatment and D&C fails, another option is removal of the uterus. Uterus being of normal size, can be removed through the vaginal route. Pain after surgery is minimal, and in uncomplicated cases the hospital stay may be limited to 3 or 4 days. Hysterectomy being a major surgery should be reserved for cases where all other means of controlling bleeding fails. Since vaginal hysterectomy is not a very morbid procedure,& there is a 100% possibility of cure, some doctors do not wait to try methods like medicated intrauterine devices or endometrial ablation before going in for hysterectomy. However, it must be remembered that hysterectomy is certainly associated with more complications compared to the non surgical treatment modalities. In India where there is no insurance cover for most patients, the cost of these procedures may seem prohibitive to some patients, and probably that is another reason why hysterectomy is preferred in many patients with dysfunctional uterine bleeding.


Questions and Answers compiled by
Dr.Shobhana Mohandas. MD.DGO.FICOG.Dip.Endoscopy.
Consultant Gynaecologist, Sun Medical and Research Centre,
Thrissur, Kerala.
Email: shobhanamohandas@yahoo.co.in.

Fibroids
Dr.Shobhana Mohandas.MD.DGO.FICOG. Dip.Endoscopy
Sun Medical and Research Centre, Thrissur, Kerala.


What are fibroids?
Fibroids are tumours found in the uterus. They are NOT cancerous by nature. Routine ultrasonography done for various symptoms show that fibroids are commonly seen in almost 40% of all women. These tumours are made of fibrous and muscle tissue and are usually seen in women who have excess of the hormone called “Estrogen” in circulation. They are usually found in the reproductive age group and may regress after the woman attains menopause. However, in the odd woman, symptomatic fibroids may be found even after menopause. There is one variety called fibrosarcoma which is cancerous by nature. But it is usually symptomatic and grows very fast. It is very, very rare and by nature cannot remain asymptomatic for long.

What are the symptoms caused by fibroids?
In many women, fibroids may remain symptom free. However, in some women, it may cause symptoms like excessive bleeding during periods, excessive pain during periods, etc.
Some patients get symptoms like increased urinary frequency, or excessive backache or pressure sensation in the pelvis.

Which are the fibroids which need medical attention?
Today, ultrasonography is being done routinely for many indications like indigestion, mild abdominal discomfort, etc. If fibroids are seen on ultrasonography incidentally at such times, they could be ignored. On the other hand, a woman may go to a doctor with specific gynaecological complaints like excessive periods, excessive pain during periods,or severe pressure sensation in the back or pelvis. If fibroids are found, either on ultrasonography or even on clinical examination, in such a situation, the symptoms are likely to have been caused by the fibroids. They require treatment.

Is it possible to cure fibroids with medicines?
No, there are as of now, no medicines which could permanently cure fibroids. There are certain injections (GnRh analogues) which can reduce the size of the fibroids,temporairily for a period of a few months. But these injections are costly . Each injection costs around Rs.5000/- They are to be administered every 28 days for a minimum of 3 injections. The tumour regresses temporarily and recurs after about 6 months. This sort of treatment is useful when one wants to postpone surgery for some reason or other. It cannot be construed as a permanent treatment. Drugs like letrozole and mifepristone have also been tried, but permanent cures are not reported.

What are the complications of a pregnant woman getting fibroids?
Fibroids may grow in size along with the uterus. It may cause abdominal pain in some patients. Rest and painkillers that are safe in pregnancy may help tide over this period. Generally fibroids are not interfered with in the pregnant state. Some fibroids may cause obstruction to labour necessitating a caesarian section for delivery. In the past, it was thought it was best not to remove the fibroids at the time of caesarian section. However, currently many surgeons, including the author have successfully removed many fibroids at the time of caesarian section, so that the patient does not need a second surgery to get rid of them.

What is the treatment for fibroids?
The 3 modalities of treatment for fibroids are:
1.Surgery to remove the fibroids only (Myomectomy)
2.Surgery to remove the uterus along with the fibroids
3.Nonsurgical embolization therapy which will necrotize the fibroids.

What are the indications for active intervention in a case of fibroids?
Active intervention in case of fibroids is necessary only in severely symptomatic patients. In infertile patients, surgery for fibroids need be done only if fibroids are thought to be the cause of infertility.

What are the indications for hysterectomy (removal of uterus) in a case of fibroids?
Hysterectomy as a treatment for fibroids is usually done only in patients who have completed their family. However, hysterectomy being a major surgery, it should be performed on a patient only if she is severely symptomatic. Certain guidelines for the performance of hysterectomy are:
A.Documented growth is > 6 cm per year (any age patient)
B.Postmenopausal patient with uterus > 12 week size or fibroid with documented growth rate > 2 cm/year
C.Patients age 30 years to menopause who do not wish further children
1.Documented fibroid > 20 week size with or without symptoms
2.Documented fibroid 12-20 week size and one of the following:
a.Documented submucous fibroid with persistent bleeding,unresponsive to medical therapy, or
b.Urinary retention, frequency or incontinence or difficulty evacuating stool
c.Uterine bleeding for more than 8-10 days in the last 2 cycles or last 40 days, and Hgb < 10 (or transfusion within the last 6 months), or
d.At least 6 months of moderate to severe pelvic pain, interfering with daily activity .
3.Fibroid < 12 week size and one of the following:
a.Documented submucous fibroid with persistent bleeding, unresponsive to medical therapy, or
b.Uterine bleeding for more than 8-10 days in the last 2 cycles or last 40 days, and Hgb < 10 (or transfusion within the last 6 months).

In patients in the reproductive age group, who have completed their family, there may be a debate on the wisdom of removing the uterus. It is generally felt that removal of the uterus may jeopardize the blood supply to the ovaries and stop its function prematurely. This may lead to the patient getting perimenopausal symptoms like hot flashes, sweating, etc much before the actual time of biological menopause. Hysterectomy is also known to predispose to urinary symptoms later on. In view of all these factors, some doctors prefer not to remove the uterus even if the patient has completed child bearing.Instead of removing the uterus, myomectomy, a surgery which removes only the fibroids is done. Surgery for removing only the fibroids is technically associated with more blood loss. Besides that, the tendency for formation of fibroids being inherent, the patient is also liable to have a recurrence of symptoms. Thus, weighing the pros and cons of hysterectomy vs myomectomy, a mature decision has to be taken.

Are there different ways of doing a hysterectomy in a patient with fibroids? What are they?
Hysterectomy can be performed by various methods, viz,abdominal, vaginal,Laparoscopic,&Laparoscopically Assisted vaginal hysterectomy.

Abdominal hysterectomy:
Hyserectomy in the traditional way was performed by making an incision in the abdomen.
This is called abdominal hysterectomy. The patient is kept in the hospital for 5-7 days depending on the time taken for removing the stitches and wound healing. The patient has to convalesce at home for a month and she has to atvoid lifting heavy objects for 6 months, the time taken for internal defects to heal. In the first few days after surgery, generally there is some amount of pain and assistance may be needed for getting up from bed, moving towards the toilet, etc, as abdominal incisions tend to be painful. The degree of mobility achieved by a patient after surgery varies from patient to patient depending on each patient’s pain threshold ,length of incision, etc.

Vaginal hysterectomy:
In vaginal hysterectomy, the uterus and fibroids are removed by making an incision in the vagina. The uterus being very large in the presence of fibroids, it is usually removed after morcellation and is taken out piecemeal. The patient is kept in the hospital for 2-3 days. She can join her duties after a week or so and it is not mandatory to avoid heavy labour for a long period.

Advantages:
There being no wound on the abdomen, the patient has very minimal pain post-operatively.
The patient does not need assistance for doing routine chores like walking, going to the toilet,etc from the very next day of the operation. This procedure is associated with fewer complications. Chances of injury to the ureter are less with this procedure. Moreover, there being no incision on the abdomen, there are no chances of incisional hernia. Wound infections are minimal.

Disadvantage: Technically vaginal hysterectomy is more difficult to perform for the average gynaecologist and thus the facility is available only in selected centers. The cost of therapy is the same for both the procedures.

Laparoscopic hysterectomy: The whole procedure is done laparoscopically. Laparoscope is an instrument through which the contents of the abdomen are visualized through a telescope introduced through a small 1cm incision below or in the umbilicus. The intraabdominal organs are visualized n a TV screen via a CCD camera fitted on to the telescope. The connections of the uterus are severed through instruments inserted through small 5mm incisions on the abdomen and the final removal achieved through the vagina. Sometimes, part of the connections is released laparoscopically and the rest released vaginally. This is called laparoscopic assisted vaginal hysterectomy (LAVH). The after effects of hysterectomy are the same as if the procedure is done vaginally. There is minimal pain and hospital stay is reduced. The choice of performing the surgery either vaginally or with the use of the laparoscope depends on the surgeon’s preference and the type of illness.

If a patient who is infertile has fibroids, is it necessary to do a myomectomy?
Superficial, small fibroids will not interfere with conception and may be left alone. But some fibroids are situated in particular areas which may be harmful to conception. These may need removal. Again, if after prolonged treatment for infertility the patient does not conceive and there is no abnormality seen except for the fibroid, then, it may be worthwhile to remove the fibroid.

What are the ways in which myomectomy may be performed?
Myomectomy, or the surgery for removing the fibroids may be performed by laparotomy, laparoscopy or through the hysteroscope. Laparotomy: This is the traditional route by which fibroids are removed. The abdomen is opened, usually through a low transverse incision to remove the fibroids. It involves a longer hospital stay and convalescence period, like any other laparotomy.

Laparoscopic myomectomy. The white tumour in the center is the fibroid. The edges of the wound have to be sutured endoscopically. Laparoscopy: The procedure is done through 3 or 4 tiny holes in the abdomen, with the help of the laparoscope. This can be done only in specialized centers as it involves suturing the uterus using needle and thread looking at a TV-monitor. Even in specialized centers, if there are multiple fibroids, there are chances that deep fibroids may be missed and left alone.

Hysteroscopy: In patients with fibroids that protrude into the lumen of the uterus, it is best to remove them hysteroscopically. Hysteroscope is an instrument shaped like the laparoscope. It is a tubular scope with a camera attached at one end. It is introduced into the uterus via the vagina. The fibroids protruding into the uterus are removed using cautery. There are no incisions anywhere on the body and the patient can start working almost immediately. This procedure is reserved for only small fibroids protruding into the uterine cavity.

What is the nonsurgical and permanent solution to fibroids?
Of late fibroids are being treated by “Embolization therapy.” Through a small prick in the groin area, the main vessel supplying the lower limb, viz, the femoral artery is cannulated. The cannula is then guided into the uterine artery, the main blood vessel supplying blood to the uterus. Some particles are injected into this main vessel to block it and thus the uterus is deprived of it’s main supply of blood. This causes the fibroids to degenerate and undergo necrosis. The uterus does not atrophy as alternate channels of blood supply take over and supply enough blood to the uterus to keep it functioning, but not enough to allow fibroids to grow. The procedure can be done in any center with an angiography machine. It requires specialized skills in radiology. The patient may get abdominal cramps after the procedure and can be discharged from the hospital in a day or two. At present, the procedure is not recommended for women who have not completed childbearing.

FAQ’s prepared by
Dr.Shobhana Mohandas. MD.DGO.FICOG.Dip.Endoscopy.
Consultant Gynaecologist, Sun Medical and Research Centre,
Thrissur, Kerala.
Email: shobhanamohandas@yahoo.co.in.

Hysterectomy
Dr.Shobhana Mohandas. MD.DGO.FICOG.Dip.Endoscopy
Sun Medical and Research Centre, Thrissur, Kerala


Hysterectomy is one of the most common operations performed on a woman. Hysterectomy is the surgical removal of the womb, i.e., the uterus.Uterus is the seat of the child before birth, and after the woman has completed her family, many consider it a redundant organ, which has a high potential to cause detrimental effects to the life of the woman. On the other hand, many consider the uterus to be pivotal in maintaining their “feminity” and are unduly concerned about hysterectomy. The various aspects of hysterectomy, from indications for hysterectomy, routes of removal, the after effects and potential complications are discussed below.

Q: What are the common indications for hysterectomy?
A:Indications for hysterectomy are:
Excessive bleeding during periods. A woman on an average menstruates every 28 to 35 days. She bleeds for 4-7 days, the flow on average being 80ml, where she changes 2 pads per day on the first 2-3 days. Some women bleed more than this from the first onset of periods (menarche) itself and continue till they stop menstruating (menopause). This may happen normally without any pathology. However, when excessive bleeding occurs in a woman from a short period, where she was getting regular periods before, it is a cause of concern. Excessive bleeding during periods, (menorrhagia), could be due to various reasons. Some of them may be amenable to medical treatment. Yet some others may respond to a variety of treatment modalities short of hysterectomy. Some of the conditions, which may necessitate hysterectomy in a patient with abnormal bleeding and the alternative therapies available for these conditions, are listed below.

Dysfunctional uterine bleeding
It means disorderly or heavy menstrual bleeding in a woman, where there does not appear to be any structural abnormality in her pelvic organs. It is usually caused due to abnormal levels of hormones in a woman’s blood . For example a woman may have heavy bleeding and her gynaecologist, on examining her might find normal uterus and no palpable masses anywhere. Ultrasonography, (a modality of investigation used by most gynaecologists to corroborate their clinical findings) may show normal sized uterus and ovaries; such cases generally do not warrant hysterectomy. The modalities of treatment available for such patients are:

Medical treatment using various hormone preparations or other drugs, which can reduce bleeding. .
Progesterone releasing intrauterine devices; in patients who cannot tolerate oral medications, progesterone containing intrauterine devices are available in the market for a cost of around Rs.6000-7000. These are t-shaped devices wrapped with coils which release the hormone progesterone continuously for about 5 years. The side effect of this device is the bothersome intermenstrual bleeding which may come on in the first few months of inserting the devce. If one could tide over this periiod, the rest of the months with this device may be smooth.

3. Ablation of the endometrium. In dysfunctional uterine bleeding, since, there is abnormal development and shedding of the endometrium, (The inner lining of the uterus). it may be useful to remove the endometrium to solve the problem. This can be done by a variety of techniques. Some of them are:

a. Thermal ablation: A warm solution is passed into a balloon like bag placed inside the uterus. The heat of the solution, passing through the balloon is transmitted onto the endomtetrium, which is dessicated. This procedure can be done in a few minutes time and may not need anaesthesia. The woman, after the procedure may totally stop having periods, or have lighter periods. In the initial few months, a small percentage of women may experience a temporary continuation of heavy bleeding, which can be tided over with drugs. The results are quite satisfactory in 80% of patients. Thus in patients where medical treatment fails, It may be a safer and simpler procedure compared to hysterectomy.

b.Microwave ablation: The endometrium is ablated using microwaves.
c. TCRE: Transcervical resection of endometrium. The lining of the uterus, in this procedure, is ablated using electrical energy using hysteroscope, an equipment which is introduced into the uterus through the vagina. This procedure requires a lot of technical expertise and has more reported complications compared to thermal ablation. However, it is a less invasive procedure compared to hysterectomy

Hysterectomy: In patients where the above modalities of treatments either fail, or are not preferred by the patient, hysterectomy or removal of uterus may be resorted to.
Functional uterine bleeding: When a definite cause for bleeding can be found in the reproductive organs to account for the excessive/irregular bleeding, it could be called functional uterine bleeding. Some of the common conditions necessitating hysterectomy are:

Fibroids
Fibroids are tumours found in the uterus. They are NOT cancerous by nature. Routine ultrasonography done for various symptoms show that fibroids are commonly seen in almost 40% of all women. In many women, fibroids may remain symptom free. However, in some women, it may cause symptoms like excessive bleeding during periods, excessive pain during periods, etc. Some patients get symptoms like increased urinary frequency, or excessive backache or pressure sensation in the pelvis.

The 4 modalities of treatment for fibroids are:
1.Surgery to remove the fibroids only.
2.Surgery to remove the uterus along with the fibroids.
3.Nonsurgical embolization therapy, which will necrotize the fibroids.
4. Medical therapy with injections, which may have a temporary effect.

Hysterectomy as a treatment for fibroids is usually done only in patients who have completed their family. However, hysterectomy being a major surgery, it should be performed on a patient only if she is severely symptomatic. Certain guidelines for performance of hysterectomy are:
A.Documented growth is > 6 cm per year (any age patient)
B.Postmenopausal patient with uterus > 12 week size or fibroid with documented growth rate > 2 cm/year.
C.Patients age 30 years to menopause who do not wish further children
1.Documented fibroid > 20 week size with or without symptoms
2.Documented fibroid 12-20 week size and one of the following:
a.Documented submucous fibroid(fibroids located nearer the middle portion of the uterus) with persistent bleeding,unresponsive to medical therapy, or
b.Urinary retention, frequency or incontinence or difficulty evacuating stool
c.Uterine bleeding for more than 8-10 days in the last 2 cycles or last 40 days, and Hb < 10 (or transfusion within the last 6 months), or
d.At least 6 months of moderate to severe pelvic pain, interfering with daily activity 3.Fibroid < 12-week size and one of the following:
a.Documented submucous fibroid with persistent bleeding, unresponsive to medical therapy, or
b.Uterine bleeding for more than 8-10 days in the last 2 cycles or last 40 days, and Hgb < 10 (or transfusion within the last 6 months).

Should the uterus be removed in a woman with symptomatic fibroids?
In patients in the reproductive age group, who have completed their family, there may be a debate on the wisdom of removing the uterus in patients with fibroids needing treatment. Removal of the uterus may jeopardize the blood supply to the ovaries and stop its function prematurely. This may lead to the patient getting perimenopausal symptoms like hot flashes, sweating, etc much before the actual time of biological menopause. Hysterectomy is also known to predispose to urinary symptoms later on. In view of all these factors, some doctors prefer not to remove the uterus even if the patient has completed child bearing.

Instead of removing the uterus, myomectomy, a surgery, which removes only the fibroids, is done. Surgery for removing only the fibroids is technically associated with more blood loss. Besides that, the tendency for formation of fibroids being inherent, the patient is also liable to have a recurrence of symptoms. Thus, weighing the pros and cons of hysterectomy vs myomectomy, a mature decision has to be taken.

Adenomyosis:
In this condition, the walls of the uterus are thickened as a whole due to depositions of endometrium(lining of the uterus). The women generally present with severe abdominal cramps, starting much before the menstrual periods and continuing through out the days of menstruation. Some of them also present with abnormal and heavy uterine bleeding in addition to pain. The only remedy is to take medicines to relieve pain. But if the pain is incapacitating and cannot be controlled with medications, hysterectomy may have to be resorted to.

Severe lower abdominal pain.
Fibroids and adenomyosis, described above could also be causes for painful menstruation and even severe abdominal pain;Besides these causes, abdominal pain could be caused by
Endometriosis. 2. Long standing infections. 3. Post-operative adhesions. 4. Pelvic venous congestion.

Endometriosis:
In this condition, there are lots of abnormal tissues found outside the womb or uterus. These are called endometrial implants. These implants cause the organs around the uterus, like ovary, tubes, intestines etc to get stuck to each other and to the uterus. Sometimes, this may cause incapacitating pain to the patient.

Laparoscopy: Inserting an instrument called laparoscope into the abdomen and removing these implants and releasing the organs adherent to each other may provide relief for a long time. However, the condition may recur, as one of the theories for causation of endometriosis is that endometriosis is caused by the retrograde flow of menstrual blood through the fallopian tubes into the abdomen. What it means is that, menstrual blood, instead of going through the vagina goes retrograde, and goes backwards into the tubes of the uterus and into the abdominal cavity. Science has yet to find a technique to medically prevent endometriosis on a permanent basis. Thus in the woman suffering from endometriosis, there is a high chance of recurrence of the disease.

Medical treatment: The other modality of treatment for endometriosis is medical treatment, which is also temporary. In a very young woman, even if her family is complete, it may be prudent to try medical treatment or conservative surgery like laparoscopic ablation of endometrioid implants and release of adhesions causing pain.

Hysterectomy: In older woman, hysterectomy is the better option. Studies have shown that endometriosis in this subgroup, is best treated by hysterectomy along with removal of both ovaries.

Long-standing infections:
When a woman suffers from repeated infections in her pelvic organs, it may lead to chronic pelvic pain. Hysterectomy for this condition is being done less and less frequently. However, some patients tired of long standing medical therapy may prefer hysterectomy.

Cervicitis:
Long standing infection in the cervix (the mouth of the uterus) might lead to inflammation in the cervix, which is called cervicitis. This causes abnormal vaginal discharge, and in some women, a nagging pain in the lower back. In the past if this complaint was not amenable to medical treatment, hysterectomy was done to relieve the patient of pain. Now, there are many modalities of treatments, like cryosurgery, laser ablation, etc, which could assist in the healing of the cervix. Thus hysterectomy is now seldom done for this complaint.

Post-operative adhesions:
Any patient who has undergone surgery can have intestines stuck to her uterus. This can cause intermittent pain in the abdomen. It generally happens when food passes through this segment of the intestine. At other times the patient feels all right. It is difficult to diagnose this condition on ultrasound scan and the pain being only intermittent, many of the patient’s relatives or friends may attribute the pain to mental tension and this prolongs the patient’s agony. Finally out of frustration, many a gynaecologist may end up doing a hysterectomy for this condition. However, laparoscopic release of adhesions is the correct treatment for this condition and not hysterectomy.

Pelvic venous congestion
Pelvic venous congestion is a condition where there are dilated veins by the side of the ovaries. This may cause nagging pain in the pelvis, white discharge, painful intercourse, etc. Again, the only way to diagnose this condition is through the laparoscope or through a specialized investigation called the pelvic angiogram. Treatment for this condition is medical and not surgical. When nagging pain keeps on recurring, many a patient might end up with a hysterectomy thinking that removal of uterus will end all problems. However, pain caused by pelvic venous congestion will not stop with hysterectomy. Even after hysterectomy, the patient may need continued medical treatment. In fact, medical treatment is the only solution to this condition and not hysterectomy.

Prolapse of the uterus:
The uterus, descends to due weakness in it’s supporting structures called ligaments. This gives the patient a feeling of some organ coming down in her vagina. In later years of the post menopausal stage, in a majority of patients, descent of the uterus is usually accompanied by descent of bladder and rectum causing symptoms of incomplete evacuation of urine and also incomplete defaecation. In India, such patients are cured by vaginal hysterectomy with tightening of bladder and rectum. However, recently a lot of procedures, where meshes are placed in the vagina to elevate the uterus and bladder and rectum have come, but due to the meshes being costly and due to paucity of enough controlled studies espousing the use of these meshes, they have not come into vogue much in India.

Tumours in the pelvis:
Cancer and precancerous lesions of the cervix :
Precancerous lesions of the cervix like dysplasias and non-invasive precancerous cancer-in-situ can normally be treated with excision of the lesion and surrounding cervix. However, in India, women generally prefer definitive surgery and thus prefer hysterectomy even for such lesions.

Established Cancer of the cervix should be treated by an extended hysterectomy. When hysterectomy is done for such patients, it has to be accompanied by removal of all the lymph nodes, which drain the organ. These are small white peanut like structures lying in clusters in various parts of the body. Removal of these nodes along with hysterectomy needs expertise and is fraught with a higher complication rate compared to ordinary hysterectomy.

Cancer of the endometrium : In this condition, hysterectomy with removal of both ovaries is the only answer.

Cancer of the ovary: In this condition, uterus and both ovaries along with a lot of extensive surgery may sometimes be needed.

What are the various ways in which hysterectomy could be done?
A: Hysterectomy or removal of the uterus is being done by various methods today.

Abdominal hysterectomy:
Hysterectomy is traditionally performed through the abdominal route when the uterus is not prolapsed. A 6-10cm cut is made in the abdomen either just above the hairline or in some cases, vertically somewhere in the middle of the lower abdomen.

Hysterectomy done in this manner is associated with pain in the days following surgery at the incision site. The patient is kept in the hospital for 5-7 days depending on the time taken for removing the stitches and wound healing. The patient has to convalesce at home for a month and she has to avoid lifting heavy objects for 6 months, the time taken for internal defects to heal. In the first few days after surgery, generally there is some amount of pain and assistance may be needed for getting up from bed, moving towards the toilet, etc, as abdominal incisions tend to be painful. The degree of mobility achieved by a patient after surgery varies from patient to patient depending on each patient’s pain threshold, length of incision, etc.

Vaginal hysterectomy:
Uterus is closest to the natural opening in the woman, the vagina. When hysterectomy is done vaginally, a cut is made into the vagina, and the attachments of the uterus to the body are severed through the opening thus made and the uterus delivered out. The incision on the vagina does not cause pain to the patient, as it is generally not as sensitive as the skin.

Advantages:
1.When the procedure is done entirely through the vaginal route, there is no incision on the abdomen. As there is no incision on the abdomen, there is no chance of wound infection or incisional hernia.

2.The patient has very little pain and is very comfortable while bending, turning over, walking, etc from the second day itself after surgery. The patients normally go home on the 3rd post-operative day and are even allowed to travel by bus. They can resume normal duties within 7-10 days of surgery.

3.Internationally, various studies have shown that ureteric injuries are fewer when hysterectomy is performed this way.
Disadvantage: Technically vaginal hysterectomy is more difficult to perform for the average gynaecologist and thus the facility is available only in selected centers with gynaecologists trained in the procedure. The cost of therapy is the same for both the procedures.

Laparoscopic hysterectomy:
Hysterectomy is completed using an instrument called the laparoscope. Laparoscope is an instrument through which the contents of the abdomen are visualized through a telescope introduced through a small 1cm incision below or in the umbilicus. The intra-abdominal organs are visualized on a TV screen via a CCD camera fitted on to the telescope. The connections of the uterus are severed through instruments inserted through small 5mm incisions on the abdomen and the final removal achieved through the vagina.

Laparoscopic assisted vaginal hysterectomy:
Sometimes, parts of the connections are released laparoscopically and the rest released vaginally. This is called laparoscopic assisted vaginal hysterectomy (LAVH). The after effects of hysterectomy are the same as if the procedure is done vaginally. There is minimal pain and hospital stay is reduced.

Total laparoscopic hysterectomy: The connections of the vagina to the body are not interfered with, and the whole procedure of hysterectomy is performed laparoscopically,.

Which is the best route of hysterectomy?
Hysterectomy done by the vaginal or laparoscopic method is defininitely advantageous to the patient by way of comfort in the post-operative period as compared to abdominal hysterectomy. However, as traditionally hysterectomy was done by the abdominal route, the average gynaecologist is trained to do abdominal hysterectomy for most indications, except when the uterus is prolapsed.

Vaginal hysterectomy in a non descent uterus, laparoscopic hysterectomy, etc require special training, commitment on the part of the surgeon, and specialized equipment and back-up facilities like staff who can help use the instruments. Thus the odds that the procedure will be completed without opening the abdomen when the procedure is posted for laparoscopic or vaginal hysterectomy depends a lot on the skill of the operator.

The degree of pain after these procedures depends a lot on the indication for which hysterectomy is done and the amount of manipulations the operating surgeon does while doing surgery. Patients who have a lot of adhesions in the abdomen do tend to get more pain than patients who have no adhesions. Adhesions are found in patients with history of previous surgery, history of infections,in patients with endometriosis, etc.

It is claimed that laparoscopic surgery is assossiated with less pain compared to vaginal hysterectomy, but we do not have large studies to vouch for the fact.

Besides pain, larger uteri and presence of adhesions make hysterectomy more difficult whichever the route employed. Thus, when hysterectomy is done for large fibroids, or for women who have undergone surgery before, there is a greater tendency for the surgeon to employ the abdominal route for surgery. If the case is posted for vaginal/laparoscopic hysterectomy, there is a greater chance for inadvertent opening of the abdomen. In the hands of experts, there is less likelihood for opening the abdomen even when hysterectomy is done for such indications.

There is less chance for ureteric injuries when hysterectomy is done entirely through the vaginal route.

Otherwise, injury rates are comparable by all methods. Ureteric injuries were supposed to be higher in the laparoscopic group when staplers were used to clamp vessels. Most surgeons in India do not use this equipment, being costly.

There are a few surgeons in India and abroad who do laparoscopic hysterectomy and send their patients home in a few hours. These are exceptions and not the rule and cannot be applied to all centres doing laparoscopic surgery.

Thus the choice of hysterectomy largely lie in the hands of the surgeon doing the surgery, depending on the skill and expertise available in her/his hands and the facilities available in that particular centre. Opening the abdomen for hysterectomy is not needed often in good laparoscopic centres and laparoscopic/vaginal surgery should be the best option for the patient who has access to such centres.


Questions and Answers compiled by:
Dr.Shobhana Mohandas. MD.DGO.FICOG.Dip.Endoscopy.
Consultant Gynaecologist, Sun Medical and Research Centre,
Thrissur, Kerala.
Email: shobhanamohandas@yahoo.co.in.

Infertility
Dr.Shobhana Mohandas.MD.DGO.FICOG. Dip.Endoscopy
Sun Medical and Research Centre, Thrissur, Kerala.


Q:When should a couple worry about infertility?
A:Ordinarily, if a couple stays together for 6 months without using contraceptive methods unable to conceive, it may be time to investigate for infertility. If the woman has grossly abnormal menstrual periods, investigations may be started much earlier.

Q:What is the normal physiology of fertilization?
A: Normally, a woman produces ova from her ovary. The ova are extruded out every month at about the 14th to 16th day of the cycle. This process is called ovulation. These ova are picked up by finger like tubular organs attached to the womb (uterus) called fallopian tubes. The ovum travels through the fallopian tube to reach the uterus. The sperm from the man enters the woman’s vagina , uterus and from there, goes into the fallopian tube to meet the ovum to form a zygote, which is the smallest form of the beginning of human life. This zygote then enters the uterus and lodges there to develop into a foetus and gradually grows there till the woman delivers the baby.

Q:Why does conception not occur in the first cycle after marriage in all couples?
A: All couples who cohabitate together do not conceive immediately after marriage even if they have not been using contraception for the following reasons:
A woman may not ovulate in all cycles.
The sperm may not meet the ova in spite of being near it.
The zygote may not lodge properly in the uterus.
This fact is important to remember in patients with infertility. When a couple starts infertility treatment, they should not be disappointed unduly in case they do not get positive results in the first or second cycle of trying for a conception.

Q: What are the causes of infertility?
A: The main causes of infertility are:
1. Poor quality of the husband’s sperms. Normally there are 20million sperms per ml of semen. Decrease or absence in count, motility etc of sperms may result in infertility.
2.Anovulation, meaning lack of regular ovulation occurring from the woman’s ovary. Usually such women have irregular periods.
3. Block in the fallopian tubes due to birth defects or infections.
4. Abnormalities in the cervix which is the mouth of the uterus.
5. Some immulogical problem, by which the man or the woman may produce antibodies against the sperms or ova which render them ineffective.

Q: What are the social causes of infertility?
A: 1.Poor quality of sperms can be worsened by smoking and alcoholism.
2.Excessive heat can be a deterrent for the production of sperms.
3.Excessive weight gain as well as excessive weight loss in the female can lead to hormonal disturbances which can lead to anovulation or oligoovulation. Overweight women would do well to cut down on sweets and fatty foods and to exercise regularly . These simple and cheap measures could go a long way in regularizing ovulation.
4.Infertility causes a lot of mental tension. Mental tension can affect the hypothalamus, an organ in the brain which controls the production of all female reproductive hormones necessary for proper ovulation and conception. This is the reason why a lot of women conceive spontaneously when they are not on any treatment and are not planning actively for conception. The tension release in these months probably removes any hypothalamic block that may be posing a problem for conception.
5.Long working hours prevent couples from cohabitating normally, thus causing apparent infertility. Similarly, couples, where the husband is staying abroad, or in another part of the country also suffer from apparent infertility. The couple start trying for conception in the 2 or 3 months that the husband is in station, which may prove inadequate for normal conception. This leads to over treatment for infertility as fertility has to be artificially enhanced in the months that the husband is in station.

Q:What are the basic evaluations a couple will have to undergo in case of infertility?
A: The basic evaluations in a case of infertility are
Clinical history and examination
Blood tests
Semen Analysis.
Specialised investigations.

Clinical history and examination
Male:Since 50% of infertility is caused due to poor quality of semen, a semen analysis is mandatory in all cases of infertility. If there are abnormalities in the semen, the man should by evaluated by way of history and physical examination. History might reveal noxious factors like smoking, alcoholism, working in an overheated environment,erectile dysfunction, etc, which could be remedied. Physical examination may reveal enlarged veins near the scrotum which is called varicocoel. The presence of significant varicocoel may mandate surgical correction. Female: The main points in clinical history of a female are menstruation, coital history and history of abnormal vaginal discharge. Menstruation: Irregularities in menstruation could be an indication of hormonal imbalance. Hormonal imbalance results in anovulation, where the ovum required for fertilisation is not released by the ovary.

Regular coital history: Infrequent coitus may lead to infertility if the couple co-habitate in the nonfertile periods of the cycle. This is particulary important in couples with different working hours or couples who stay separately and meet only occasionally. Care should be taken to see that the couple are together in the fertile period of the cycle.

Stress: Stress can cause anovulation and a couple desiring pregnancy should learn to cope up with the stress inherent in the investigation of infertility. It is easier said than done, as there is a lot of pressure from social and family circles when the couple do not concieve for a long time. This coupled with the tedious investigations and frequent visits to the gynaecologist can be stressful. However, it is important for the couple to find some ways to let out their emotions and remain stressfree, so that they get better results out of their infertility treatment.

Abnormal vaginal discharge: At the time of first visit, gynaecologist are generally very diligent and look for abnormal vaginal discharge and ask for presence of itching or copious vaginal discharge. The clear watery discharge coming about 15 days before menstruation is normal and is helpful for sperms to reach the uterus.. However, if there is foul smelling discharge, or itching in the private parts, it is indicative of infection in the vagina or cervix. This may be harmful for the sperms entering the vagina and will contribute to infertility. This is usually taken care of by many gynaecologists by routinely prescribing a course of antibiotics, antifungal and antitrichomonal agents, which are tablets which kill organisms causing vaginal infections.

However, when the couple have been infertile for a long time, this aspect tends to get forgotten. This may be a reason why when some major factors contributing to infertility have been treated, the couple continues to remain childless, as this minor factor is forgotten. Thus it is important for the infertile couple to report to the gynaecologist any change in her vaginal secretions, at any point during the treatment for infertiliy.

Clinical examination:
A good clinical examination by the infertiliy specialist can detect many abnormalities, which may then be corroborated with findings of investigations. Some factors that doctors detect through clinical examination are as follows:
Improper intercourse: Surprisingly, some couples who come for infertility treatment are found to not even have undergone normal coitus. This happens sometimes because, they are either unaware of how intercourse should be done or sometimes because the man has difficulty in attaining erection. Embarassment prevents them from disclosing this to their doctors and in this era where many doctors rely more and more on investigations and less and less on clinical examination, this deficit remains undiagnosed, specially when some glaring deficits like low sperm count or very irregular periods is present. When gross abnormalities are present, the onus of investigations shift to correct these abnormalities and sometimes the lack of intercourse remains undetected!!! Polyps: Simple growths like polyps near the mouth of the uterus could be revealed by a proper clinical examination.
Galactorrhoea: Expression of milk or a watery discharge from the breasts (Galactorrhoea) could be an indication of increased levels of a hormone called prolactin , which could cause infertility.
Hirsuitism: Presence of hair on the upper lip, or a male distribution of hair on the abdomen, could be an indication of abnormal hormone levels in the body. However, it must be remembered that not all women with hair on the upper lip have abnormal hormone levels. Some could be having just familial hirsuitism. Body weight: Both excessive weight gain, as well as excessive weight loss are deterrants for normal ovulation.

Investigations
After a good clinical examination, investigations will have to be done on the husband and wife to detect abnormalities which need attention. The following investigations will need to be done in the male and the female.

Semen Analysis
Male infertility affects almost 50% of infertile couples. A simple semen analysis would rule out male factor straight away. Semen should be collected in a clean, dry, wide mouthed container after 2 days of abstinence. The specimen is collected after masturbation in the laboratory. Some men prefer to collect it at home and in that case, the specimen should be handed over to the labarotary within half an hour noting the time of collection.

Female factors
Ovulation studies:
Various tests can be done to find out if a woman is ovulating or not. BBT: Basal body temperature:A woman is asked to record her temperature first thing in the morning, before getting up or having any beverages. The temperature varies mildly over the days. If the temperature rises and falls twice in the month, around midcycle, the temperature chart is said to be biphasic and indicative of ovulation. However, this is a retrospective test and can only tell that ovulation has occurred/not occurred. It cannot predict when ovulation will occur and thus it is not helpful in planning intercourse.

Ultrasonography:
A woman is asked to undergo ultrasonography every two days ,starting from the 10th day onwards till ovulation is confirmed. The ultrasonogram documents the growth of the follicle in the ovaries. The follicle gradually grows from a size of 8 mm till it reaches 18mm and in a couple of days is seen no more. This is indicative of ovulation. . Doctors use this modality of testing quite frequently to know whether a patient is ovulating , so that intercourse can be timed appropriately and also sometimes to find out if medications given for inducing ovulation are working properly or not.

LH kits: Urine is tested on alternate days and a special paper is inserted into it. The change in colour in the dipstick is used to indicate ovulation. This can be done by the patient at home itself and avoids the necessity of visiting the doctor every 2 days. But the overall cost of testing per cycle would be higher than that of serial ultrasonography done by most sonology centers.

Tubal studies:
As mentioned before, the uterus is connected by two tubes which communicate with the abdominal cavity. These tubes are responsible for the transport of the ovum , the sperm and in case of successful fertilization, the transport of the embryo into the uterus. It is done rather invasively by vaious modalities.

Tube testing: It is the local language used for testing the tubal patency by injecting air into the uterus. The gush of air in the abdomen in the case of patent tubes can be heard through the stethoscope. It is a very crude form of investigation . It is hardly ever performed in full-fledged institutions. Hysterosalpingogram: In this test, a radio-opaque dye is injected into the uterus. The path of the dye is recorded on an X-ray film. The dye normally passes through the uterus into the tubes and finally into the abdomen proving that the tube is open. This test can be done on a day care basis, but if there is block in one of the tubes, it can be quite painful.

Sonosalpingogram: Any plain fluid is pushed into the uterus and the ejection of the fluid into the abdomen is recorded on sonography. Unless very high resolution ultrasonograhy machines are used, it may not be as accurate as the hysterosalpingogram.

Laparoscopy: Generally in current practice, laparoscopy is not used as a routine investigation to test the patency of the tube. But if a patient does not conceive after a reasonable period of time inspite of treatment, a laparoscopy is done. A fluid with or without dye is injected into the uterus and the flow of dye through the tubes is observed through the laparoscope. Any abnormalities in the abdomen can be corrected at the same sitting.

Laparoscopy in infertility:
Laparoscopy is an important modality of investigation in the investigation and treatment of infertility. Laparoscopy is used to diagnose any subtle causes for infertility.

Tubal disease:
Any factor that affects the motility or patency of the fallopian tube can cause infertility. Tubal disease has been implicatedin 15-20% of couples presenting with infertility. The tubal ends are some times closed because of agglutinations. These can be released through laparoscopic instruments. Releasing adhesions between the tube, ovary, and the uterus can improve the motility of the tube

Ovarian cysts:
Sometimes in a condition called the polycystic ovarian disease, medical treatment might fail. In such cases making tiny holes in the ovary might help enhance fertility. Picture on the right shows multiple punctures made into the ovary of a woman with this problem.

Endometriosis:
Resection and vaporization of endoetriosis is the most common indication for laparoscopy in infertility. Laparoscopic treatment of endometriosis yields a pregnancy rate of upto 60%.

Laparoscopic puncture of ovaries can cure some cases of Polycystic ovaries, one of the causes of infertility.

Hysteroscopy: Usually at the time of laparoscopy itself, a scope is passed into the uterus to make sure there are no abnormalities inside the uterine cavity. In case of blocks in the tubal opening into the uterus, a cannula is passed into the opening to remove the block.

Sometimes there are polyps or fingerlike growths in the uterus, which prevent normal conception.
Presence of adhesions or small flimsy bands in the uterus can also be picked up using hysteroscopy. Correction of these abnormalities could lead to fertility.
Hysteroscopy is also useful in patients who get pregnant, but continously have abortions. One of the reasons could be presence of congenital walls dividing the cavity, called uterine septum. This can be cut using hysteroscope. Infections can also cause the walls of the uterus to stick together and this can be cut using the hysteroscope.

Q: What are polycystic ovaries: what are the options available for treatment
Normally, women develop many follicle, about 8-9mm in her ovaries. One of them become dominant and ovulate. In women with polycystic ovaries, none of the follicle are able to attain a size capable of ovulating. These women also have excess of oestrogen in them. Most of them are associated with obesity. The androgen level is quite often high in these women and they have excess hair on their upper lip and hair may grow in a slightly male pattern. there may be light pigmentation on the back, called acanthosis nigricans. Many of them have cells which are resistant to the hormone insulin, which normally digests glucose in cells. as a result some of them have excess glucose in their blood.

Treatment options:
1.drugs like Clomiphene citrate can be given for 3- 6 months. giving it for more than 6 months may be harmful .
2. Hormone injections can be given
3.Drugs like metformin and Pioglitazone can reduce insulin levels
4. In patients who cannot concieve on clomiphene, laparoscopic puncture of the ovaries is an option. This is an alternative to hormone therapy as hormone therapy is expensive.

Menopause
Dr.Shobhana Mohandas.MD.DGO.FICOG.DipEndoscopy
Consultant gynaecologist, Sun Medical and Research Centre, Thrissur, Kerala.


What is menopause?
Menopause is a term used to describe the permanent cessation of the primary functions of the human ovary. The ovary functions by releasing ova and hormones, both of which are stopped with menopause. Hormones produced by the ovary are oestrogen and progesterone. Both these hormones normally cause menstruation by their effect on the uterine lining, called the endometrium. Thus, when ovary sort of shuts down, with menopause, the effect of both these hormones cease.

When does menopause occur?
Natural menopause occurs anywhere between ages of 45 and 55. Better nutrition may delay the onset of menopause. Menopause can be artificially induced if both ovaries are surgically removed. Rarely, menopause may occur at a young age, prematurely. It is surgically induced if both ovaries are removed for some reason.

What are the changes that trigger the menopausal transition? Natural menopause is associated with lack of functioning of ovaries, which are two hormone producing organs situated near the womb or the uterus. Normally, these ovaries produce 3 hormones,viz: oestrogen, progesterone and androgens. When they stop functioning, a woman faces many physical and mental changes

What is the significance of menopause for a woman?
Menopause can have the following effects for a woman.

Irregular heavy bleeding: Before the actual cessation of periods, the periods may get delayed by 7 days or longer. Gradually a cycle may sometimes be missed and these periods of absence will finally lead to stoppage of menstruation. In some women, these changes may be accompanied by heavy bleeding. This requires medical help if it is very heavy, otherwise, she may become anaemic. Heavy bleeding also requires medical evaluation to rule out pathological causes of bleeding.

Hot flashes: The sudden sensation of extreme heat in the upper body, particularly the face, neck, and chest is referred to as a “hot flash.” Perspiration, flushing, chills, clamminess, anxiety, and occasionally palpitations can occur. They last anywhere between 1-5 minutes.

Osteoporosis: Osteoporosis literally means porous bones. Many years after menopause, the process of bone formation is not as fast as the process bone loss and this leads to less strong bones. In women, this is partly attributed to lack of the hormone oestrogen. Loss of cardioprotection : It is known that women who have not undergone menopause have less chance of getting a heart attack as compared to men of the same age. However, once her ovaries stop functioning, the odds that a woman may get a heart attack are the same as for men of comparable age. The protection provided by oestrogen is no longer there.

Hypothyroidism as a consequence of menopause. There is reduced production of a hormone called thyroxine, normally produced by the thyroid gland , situated in the neck. The woman as a consequence, may tire easily, may get water logging in her body, and in extreme cases may not be able to tolerate cold.

Depression: Women in their menopausal period may suddenly develop depressive symptoms, like easy crying, easy irritability, or sleeplessness. These symptoms are caused in some women due to fluctuating oestrogen levels, which has secondary effects in the brain. Usually at this time, the woman also faces an "Empty nest syndrome". This means, till about 40 years, her house was filled with echoes of her children asking her for something or screaming for something not done. But suddenly they leave her and fly away to be on their own. She suddenly feels unwanted and this negative feeling adds to her symptoms of depression. If it is severe, along with medicines to replace deficient hormones, she may need antidepressant medications.

Vaginal symptoms: Due to lack of the hormone oestrogen in late menopausal years, there is dryness in the vagina. There also can be itching and burning sensation. There may be small breaks in the vaginal skin in extreme cases. This can be treated with local oestrogen creams or tablets.

What are hot flashes?
Hot flushes are sudden or mild waves of heat on the upper part of the body that last from 30 seconds to a few minutes, caused by a decreased estrogen production during menopause. Hot flushes are typically experienced as a feeling of intense heat with sweating and rapid heartbeat, and may last from two to ten minutes for each occurrence. The sensation of heat usually begins in the face or face and chest, although it may appear elsewhere such as the back of the neck, and it can spread throughout the whole body. In addition to being an internal sensation, the surface of the skin, especially on the face, becomes hot to the touch. The sensation of heat is often accompanied by visible reddening of the face.

The hot flush event may be repeated a few times each week or constantly throughout the day, with the frequency reducing over time. Some women undergoing menopause never have hot flushes. Others have mild or infrequent flushes. The worst sufferers experience dozens of hot flushes each day. In addition, hot flushes are often more frequent and more intense during hot weather or in an overheated room. Hot flashes may be accompanied by perspiration and shivering, increased heart rate and/or feelings of irritation, anxiety, or panic.

Will all women going through menopause get hot flashes/flushes?
Not all women going through menopause get hot flashes. Various studies quote various figures for the percentage of women suffering from hot flashes at the time of menopause. The quoted figures vary from 56% (2) to 79%(1).

What are night sweats?
Night sweats, medically termed "sleep hyperhidrosis," are episodes of nighttime sweating, which can range from mild to profuse. They usually accompany hot flashes, and thus the usual accompaniments of hot flashes,viz: nausea, chills, headache, etc may accompany episodes of night sweats.

Will women who suffer from hot flashes and night sweats begin to suffer immediately after menopause?
Hot flashes can begin during the late premenopausal or early perimenopausal years, but they become more frequent and severe during the late perimenopausal and early postmenopausal years.3 Hot flashes can last from a few seconds to more than an hour and persist for 1 year in 95% of affected women and up to 5 years in 65% of affected women.4–6 Hot flashes are not confined to the menopause transition associated with natural age-related decline of estrogen and progesterone. Hysterectomy, by itself can, with or without oophorectomy, cause hot flashes in 95%–100% of women (3).

What are the factors that trigger hot flashes or night sweats?
Spicy foods and hot drinks can trigger hot flashes. Stress cannot trigger hot flashes, but,it is possible that stress of of midlife transitions (aging parents, empty nest, retirement) or other stressful events may increase the frequency and/or intensityof hot flashes. (4).

What is the treatment for hot flashes?
In mild cases, physical measures like avoiding synthetic clothes, spicy food, too much caffeine or alcohol, keeping a cool environment, avoiding layered clothing, etc, may help. Meditations, deep breathing exercises, and measures to reduce stress can all help.

However, in severe cases, medications called oestrogens, will be required. Treatment with oestrogen, is called hormone replacement therapy. Non-hormonal treatment like isoflavone tablets may suffice for milder symptoms. There are many other medications also available for treatment of hot flashes, for women who are not fit candidates for oestrogen treatment.

How long will a woman suffering from hot flashes have to take hormone drugs, if at all they are prescribed?
Usually hot flashes last only for 3-5 years, and drugs will be needed only for that period. However, each individual is a different person, and the duration of therapy has to be tailored as per the requirements of that person, by the doctors prescribing the medication.

Is oestrogen available in food?
Ostrogens made by plants, called phytooestrogens are available inlarge amounts in food products like soy products, and sesame seeds(til). Smaller amounts are available in chickpeas(Bengal gram, channa), garlic, Mung bean sprouts, dried apricots, dried dates, sunflowerseeds, almonds, green bean and peanuts.

They are not as potent as the oestrogens made by the human body, but they have much less side effects compared to human oestrogen. Japanese and other Asian communities who consume a lot of soy products in their diet, have fewer episodes of hot flashes.

Is Irritability at time of menopause caused by lack of hormones?
Irritability in the menopausal woman cannot be fully cured with hormones. If it is caused by hot flashes, and night sweats, hormone replacement will help. Otherwise, counseling and anti depressant medications may be needed.

My wife does not get sleep at night and feel like crying very often. Many doctors have asked her to take pills for sleeping . They say it is a psychological problem, but we have not given her any stress at home.

Crying spells and inability to sleep in the early waking hours of night are hallmarks of mental depression, caused due to reduced serotonin levels in the brain. It is not necessarily caused by stress in the house. It can be cured with medications. It may be aggravated in the menopausal woman due to fluctuations in the hormone level.

Why do women get irritable at the time of menopause.
Irritability at the time of menopause could be caused, either due to depression or due to hot flushes, which is an accompaniment of menopause.


Questions and Answers compiled by:
Dr.Shobhana Mohandas. MD.DGO.FICOG.Dip.Endoscopy.
Consultant Gynaecologist, Sun Medical and Research Centre,
Thrissur, Kerala.
Email: shobhanamohandas@yahoo.co.in.

Normal Pregnancy
Dr.Shobhana Mohandas.MD.DGO.FICOG. Dip.Endoscopy
Sun Medical and Research Centre, Thrissur, Kerala.


Introduction: Pregnancy is a unique period in a woman’s life time. Each and every moment of that wonderful period remains in a woman’s mind for years to come. The various changes that occur during one’s pregnancy, the various people who encourage you in pregnancy, and the innumerable doubts that come to one’s mind during that period, come as flash backs throughout a woman’s life.

What follows is a list of questions that a normal obstetrician faces in her day to day practice from pregnant patients. Scientific answers to those questions follow.

1. Am I pregnant?
The cardinal symptom that gives suspicion of pregnancy is the missing of normal menstruation on the expected day. This may be accompanied by symptoms like nausea or vomiting. However, a positive diagnosis of pregnancy cannot be made on these symptoms alone, for the following reasons:

Delayed periods may be caused by mental tension, change in the hormonal milieu of the woman, etc.
Similarly, nausea and vomiting may be caused by indigestion, acidity, etc.
Positive diagnosis of pregnancy in the early days is currently made by the examination of urine pregnancy kits.

Pregnancy test kits:
Urine of the pregnant woman is collected in a clean dry bottle. Most of the pregnancy kits come in the form of cards with 2 depressions in it. Urine is placed in one of the depressions and the result is read in the rectangle beside it. If there are 2 dark lines in the rectangle, the test is said to be positive, meaning, the woman is pregnant. If there is only one dark line the test is negative, meaning, the woman is not pregnant.

Timing of urine testing: The test becomes positive as early as 2 days after a missed period.
In precious pregnancies, like in women who have conceived after treatment of infertility, blood level of a substance called HCG is measured to determine if she has conceived.

Ultrasonography: The use of an ultrsonography is frequently used to confirm pregnancy. Ultrasonogram is commonly called “Scanning”or ultrasound scan. It uses sound waves to detect changes in the body organs.

The foetus, after conception usually lies in a bag called the gestational sac inside the uterus. The detection of this sac inside the uterus on scanning is confirmatory of pregnancy.The sac appears 1 week after missed period. 2 weeks after a missed period, the heart beat of the foetus can be seen on the scan, confirming that the foetus is alive.

Safety of USG: Ultrasonography is generally safe in pregnancy and there are so far no reports of any documented abnormalities in a fetus caused by ultrasonography in pregnancy. Millions and millions of ultrasonography has so far been done world over in pregnancy.

Clinical examination: Enlargement of the uterus can be perceived clinically by doing a per vaginal examination to know the enlargement of the uterus by about 15 days of missed periods. However, pregnancy kits currently can diagnose pregnancy much sooner than that, so by and large diagnosis of pregnancy is done by examination of the urine.

2. Now that I am pregnant, what are the special precautions that I should take?
In an uncomplicated pregnancy, not many special precautions need be taken. However, the following doubts may arise in the woman’s mind.

a) Should I take rest?
The fact is that many studies have shown that bed rest does not decrease the incidence of miscarriages. Even in sterility conceptions, there is no role for bedrest. A woman can continue to go for work even when pregnant. The reason why many doctors advocate bedrest in precious pregnancies is probably because bedrest does not harm any pregnant woman and it is a popular and probably unshakable belief that bedrest can prevent mishaps in pregnancy. However, if there is vaginal bleeding after a confirmed pregnancy, rest is essential.

b) Can I travel?
Ordinary travel, by bus, car, autorikshaw, aeroplane, etc is permissible in early pregnancy. However, while traveling by two-wheelers, care must be taken not to travel for long distances through very bumpy roads.

c) Is intercourse permissible?
In uncomplicated pregnancies, there is no bar for intercourse during pregnancy.

3. What special food should I take during pregnancy ?
In the first 3 months of pregnancy, many pregnant women suffer from nausea and vomiting. This is said to be a protective mechanism to ward of noxious substances in food. In the first 3 months, the organs of the baby are formed and it is theorized that this protective mechanism prevents congenital anomalies in the foetus.

Since it is a period of general uneasiness for the woman, it is best to allow her to eat whatever she fancies. There should be no restriction on food fads during this time. She should take whatever little she can at frequent intervals. If she is not able to eat solid food, taking a glass of lemonade with lots of sugar or glucose powder might help. Ginger is said to be helpful in allaying vomiting. Taking dry food stuffs like crackers early in the morning soon after getting up from bed can prevent morning sickness. High protein diet like an egg or pulses while going to sleep is also useful.

In the period after the first 3 months:
After the period of organogenesis(The time when the organs of the foetus are being shaped) in the first three months is over, the woman tends to vomit much less and she begins to tolerate food much better. From the fourth month onwards, the baby begins to grow and the mother has to provide nutrients, both for herself and for her growing baby. She has to have a balanced diet containing carbohydrates , fats, proteins , minerals and vitamins.

· The usual diet contains enough of carbohydrates. In addition , the woman should be advised to take one half –boiled egg per day to provide for proteins. In vegetarians, a diet rich in pulses and grams can act as substitutes. If this is difficult to take, there are many protein powders in the market and daily allowances of protein can be completed from them.

· The bone of the growing baby demands additional calcium supplimentation. Calcium is available in milk and green leafy vegetables. Deficiency in calcium intake can lead to high blood pressure in pregnancy.

· Pregnancy pushes the stomach up and may cause acidity. Restriction of fried foods and spicy foods can prevent aggravation of this condition.

· In pregnancy the bowel movements are sluggish due to increased levels of a hormone called progesterone. The iron and calcium supplementation during pregnancy may aggravate the constipation already caused by the sluggish bowel movements. Taking grapes, high fibre diet, like green leafy vegetables, or drinking a glass of warm water at night can relieve this symptom to some extent.

4. Symptoms of Pregnancy:
There are many symptoms peculiar to pregnancy as a result of many physiological changes in the pregnant woman’s body.

Vomiting and Nausea: The first three months of pregnancy are usually accompanied by a tendency for nausea and vomiting. Usually it is not of a magnitude that requires medication. The woman is encouraged to take frequent small meals . She should avoid oily foods. The smell of fried food may be offensive at this time and it would be useful to avoid such odours. The quantity of food taken may be inadequate due to nausea and this may lead to a feeling of being tired and sometimes giddiness may ensue. Many pregnant women and their caregivers mistake giddiness to be a sign of anaemia, high blood pressure or even some other serious illness. The difficulty of taking enough to go on with normal work can , to some extent be overcome by taking frequent sips of glucose water or sugared lemonade The solution should have high quantities of glucose, or sugar instead of the usual 2 teaspoonfuls. Glucose is a simple sugar and is digested immediately and even if the woman vomits after a while, she gets the calories she needs.

Taking dry biscuits or crackers early in the morning, high protein diet at night, etc are some other ways of combating this symptom.

Sometimes, nausea and vomiting may prove to be too much to carry on with routine activities, and at such times there should be no hesitation in taking some medications on the prescription of a doctor. Most of these medications are safe in pregnancy. Many women fear that taking medications may lead to anomalies in the baby and try to avoid them . This leads to uncontrollable vomiting. Medicines on a doctor’s prescription should be taken freely to control this symptom without fears of anomalies to the foetus.

Sometimes inspite of medication, there may be uncontrollable vomiting and this may need admission to a hospital and intravenous drips. This happens when excessive vomiting causes a condition called ketoacidosis in the body. This leads to more vomiting and further vomiting aggravates the ketoacidosis, thus creating a vicious cycle. Intravenous drips at this stage stops ketoacidosis and controls vomiting.

Some women continue to have nausea throughout pregnancy . Some of this is due to gastritis and can be controlled with simple medications.

High temperature:
The need to provide energy for the growing baby increases the metabolic rate of the pregnant woman and she may feel warm all the time. Many women feel concerned at this and feel that they have fever of some pathological origin. The presence of increased amounts of the hormone called progesterone may also contribute to slight elevations in temperature. No medications are needed for this kind of “fever”. Whenever a woman feels feverish, it is best to document the rise in temperature using a thermometer and confirm it. This will prevent undue anxiety over many a so called “fever”. However, very high temperature may indeed be due to some pathological cause and certainly needs prompt therapy. Infections may present with high temperature, and if untreated, will lead to death of the foetus.

Abdominal pain:
Pain in the abdomen causes alarm in most pregnant women.
-Occasional pain in the abdomen may be due to colics or it may be due to the presence of harmless cysts in the ovaries. These need not be a source of worry.
-If the pain is severe, medical attention is warranted, as it could be due to many conditions related or unrelated to pregnancy.
- In later pregnancy, intermittent abdominal pain may be symptom of impending labour.
-Abdominal pain just above the hairline may be due to bladder infections.
-A discomfort felt in the lower abdominal region in later pregnancy may be due to stretch on the ligaments attached to the uterus.
-Severe constipation may lead to stasis of gas in the intestines, leading to colics.

Intermittent abdominal pain in the latter half of pregnancy may be a sign of preterm labour and should receive immediate medical attention.

Burning sensation:
The growing uterus in the abdomen displaces the stomach and intestines. This leads to acidity and a burning sensation in the abdomen. Simple antacid therapy may cure it.

Backache:
The pelvis is a bony cavity which initially houses the uterus and it is through the outlet of the pelvis that the baby comes out of the body. In preparation for the birth of the baby, the ligaments, (fibrous bands uniting the bones) of the pelvis become lax. The relative increased mobility of the bones leads to backache in some patients. Back ache is aggravated by wrong postures. As far as possible , the pregnant woman should walk straight. As the abdomen enlarges, there may be a tendency for the woman to push her tummy out and this will worsen the back ache.

Normally, the baby lies with it’s back lying just below the mother’s abdominal wall. In occipito-posterior positions, the back of the baby will be in front of the maternal spine and nearby structures. The baby is literally lying on it’s back.. In such patients, backache is more pronounced. Back ache may be relieved by simple hot fomentation or local pain-relieving balms. Paracetamol tablets, normally used to treat fever is also useful for severe cases of backache. Aspirin, and other regular painkillers are best avoided in the latter half of pregnancy as these may cause abnormalities in the circulatory system of the growing foetus.

Many patients complain that when they take rest, they do not have any backache, but when they start working, they suffer from backache. It would be best to limit physical activities to the extent that does not cause backache, rather than taking a lot of medications to be able to give 100% work performance. Backache coming on at regular intervals in the latter half of pregnancy could be a sign of impending labour and needs medical intervention. Backache caused by contractions in the uterus comes at regular intervals as opposed to a continuous dull aching pain that is usually seen.

5.Traditional belief about precautions in pregnancy:
There are many do's and don'ts in Indian traditional belief . Some of them are listed below.
1.Papaya can cause abortions: Ripe papaya cannot cause abortion and is in fact rich in VitaminA.
2.Pineapple can cause abortion: There are no modern scientific studies to prove this fact.
3.Saffron flower can make the baby fair: the colour of the offspring is determined by the genetic make-up of the parents. No change in food habits of the mother can influence the colour of the baby.
4. Pregnant women should not sleep in the afternoon: We do not know why this belief came about.
5.Pregnant women should sleep on one side: This is true as the weight of the enlarged uterus will fall on the large blood vessels by the side of the spinal cord if the woman lies on her back , thus impeding circulation.
6.A woman should expose her tummy by wearing sarees during pregnancy to avoid jaundice in the newborn: There is no scientific evidence to this hypothesis

Ovarian cysts
Dr.Shobhana Mohandas.MD.DGO.FICOG. Dip.Endoscopy
Sun Medical and Research Centre, Thrissur, Kerala.


Normal women have small white organs called ovaries placed by the side of the womb. They are normally about half a lemon in size and are responsible for the production of hormones called oestrogen and progesterone in the body. They extrude human eggs or ova every month by a process called ovulation. Sometimes the follicles which harbour these ova get filled with a watery fluid or even blood . This gives rise to what are called ovarian cysts. They are basically membranous sacs in the ovary filled with fluid. More often than not, these ovarian cysts are harmless and could be left alone. But there are situations where surgical intervention will be needed.

The various types of ovarian cysts generally found are described below:

Harmless functional cysts:
Due to the routine use of ultrasonography for a myriad of conditions, ovarian cysts are normally found in many women. They could be harmless cysts which are called ‘’functional cysts”. They normally appear and disappear by themselves. By and large simple cysts that are less than 5-6 cm in size do not need any intervention. A repeat ultrasonography after 3 months may show disappearance of the cyst. If the cyst persists, it is better to have the cyst removed surgically by a procedure called ovarian cystectomy.

Twisted ovarian cysts:
Sometimes the cysts turn around or undergo a twist, so to say. This is usually associated with intermittent abdominal pain,. The pain is usually more in certain positions, like turning on to one side. Sometims it may be accompanied by vomiting.

A twisted ovarian cyst, if left alone, will have a jeopardised blood supply and this will lead to gangrene of the ovary. So whenever there is acute pain in the abdomen and an ovarian cyst is diagnosed, the woman is subjected to surgery, usually ovarian cystectomy. It can be done laparoscopically in places there are facilities to do the procedure or by open surgery.. If surgery is delayed and the ovary has undergone gangrene, the ovary will have to be sacrificed.

Endometrioma:
Sometimes the ovarian cyst is filled with dark, chocolate coloured fluid, which is old blood. This is caused in women who suffer from a disease called endometriosis. In endometriosis, a tissue called endometrium, which normally lines the uterus,is found in places outside the uterus. The uterus, normally sheds this endometrium outside at the time of menstruation. Instead, if the endometrium is found in the abdomen , the woman is said to have endometriosis. A collection of endometrium along with blood, in the ovary, which enlarges to form a cyst, is called an Endometrioma or Chocolate cyst. If it occurs in women who do not have children, it may cause infertility. The ideal treatment for endometrioma is laparoscopic ovarian cystectomy,

Endometriomas, in spite of very good surgery do tend to recur, as, the basic disease Endometriosis,with retrograde menstuation, where the menstrual blood goes retrograde into the abdomen, is not cured. Repeated ovarian cystectomies in such patients will lead to loss of precious ova. Infertile patients with recurrence of endometrioma should think in terms of undergoing procedures like Artificial Reproductive Technonlogy instead of undergoing repeated surgeries.

Benign ovarian tumours: Sometimes ovarian cysts are caused by noncancerous benign tumours like serous cystadenoma, mucinous cystadenoma, etc. These cysts do not regress and need surgical removal. The cyst can be removed by cystectomy through laparoscope or open surgery. Once removed , there is not much chance of recurrence.

Dermoid cysts: Sometimes, the ovarian cyst is filled with many tissues like hair, teeth, bone, fatty sebacious material, etc. These are called Dermoid cysts. These are called germ-cell tumours. Usually this occurs in the younger age group. Treatment is by cystectomy. There is very little chance of recurrence. In one study, after Dermoid resection, 3.4% patients were seen to have a recurrence within the study period of 6 years. Dermoids could also occur bilaterally and there is a small risk of malignancy in untreated patients. It is possible to get pregnant even after removal of Dermoids.

Malignant ovarian cysts: Malignant ovarian cysts usually occur bilaterally, although it could also occur unilateally. Ultrasonogram in such patients show solid elements in the ovarian cysts, besides the usual fluid that is seen in non-cancerous cysts. Tumour markers like CA -125 are raised in such patients. This could be detected by testing the blood. Special ultrasound examination like colour Doppler ultrasonography can show increased blood flow in the cyst.

If the cyst is malignant, in young patients, in some particular cases, it may suffice to remove only the affected ovary. In most cases, in the older age group the uterus along with both the ovaries will have to be removed . Open surgery is the preferred modallity of surgery in these patients.

Indications for surgery in ovarian cysts:
1. The cyst persists after 3 months; Persistent ovarian cysts could be caused by benign ovarian tumours and need removal.
2. The cyst is associated with pain or increase in size: Pain could be due to a twist in the ovary, which may lead to loss of blood supply to the ovary and subsequent death of the ovary.
3. Endometrioma: A common cause for ovarian cysts is an endometrioma. In this condition, menstrual blood collects over the ovary, finally ballooning it into a blood filled sac. This is called an endometrioma and the blood inside the sac is usually old blood.
4. Cancerous cysts: Cancerous cysts usually have solid components besides the usual liquid contents of simple ovarian cysts. These differences could be detected by ultrasonography. A special type of ultrasonography called colour doppler ultrasonography could detect the presence of increased blood flow in the ovary suggestive of malignancy in the ovarian cyst.
Some blood tests like CA125 levels could also be useful in the detection of malignancy.

Ovarian cysts in pregnancy:
Ovarian cysts may occur during pregnancy. If seen in the first 3 months it could be a functional cyst and could be left alone. If severely symptomatic, immediate surgery may be needed. Otherwise, doctors wait till the 4th month to see if the cyst disappears. If it persists, ovarian cystectomy may be done

Laparoscopic ovarian cystectomy is possible in pregnancy and is safe in pregnancy in experienced hands. We have done 4 cases of laparoscopic ovarian cystectomy in pregnancy in our unit and all of them had good obstetric outcome.

Disappearance of cysts:
Clinical situation: A 14 year old school girl gets mild abdominal pain off and on for 2 days and it became severe one day. She visited her physician who suspected an ovarian cyst and referred her to a gynaecologist. An ultrasonoram showed a 6 cm cyst. The girl was advised an emergency laparoscopic surgery to remove the cyst. But the girl had her school examination the next day and she refused to undergo surgery. Meanwhile, her mother solicited divine intervention from god to see that nothing went wrong with her daughter. 2 days later the pain disappeared and the girl decided not to go back to her doctors. What could be the reason? Had the doctor advised unnecessary surgery? Was it divine intervention indeed?

A: An ovarian cyst that is not associated with any discomfort could be left alone. But when there is severe pain associated with the cyst, it is ominous. Severe pain in the presence of an ovarian cyst could be due to a twist in the ovarian cyst. The twist could jeopardize its blood supply and lead to permanent damage to the ovary. This is why when a patient who has severe pain in abdomen is found to have an ovarian cyst, emergency surgery is advocated. But instead of twisting, sometimes the cyst may simply burst and this will relieve the pain. If that happens, there is a happy ending and a scenario that is described about the 14 year old girl in the question above follows. However, no doctor can prophesize whether the severe pain is a prelude to a twist in the ovary or portends rupture of the cyst. Doctors with high expertise in sonography can, with the help of a color Doppler sonography detect the twist in the ovary. But in the presence of severe pain, generally doctors play it safe and ask for an emergency surgery to be on the safe side even if the twist is not seen on ultrasonography. Generally, a twisted ovarian cyst is accompanied by other symptoms like vomiting, pain while passing urine, etc. If these symptoms are present, it is more helpful to clinch the diagnosis of a twisted ovarian cyst.

Q: Should all women with ovarian cysts undergo surgery?
A: Not all women with ovarian cysts should undergo surgery.

Indications for surgery in ovarian cysts:
1. The cyst persists after 3 months; Persistent ovarian cysts could be caused by benign ovarian tumours and need removal.
2. The cyst is associated with pain or increase in size: Pain could be due to a twist in the ovary, which may lead to loss of blood supply to the ovary and subsequent death of the ovary.
3. Endometrioma: A common cause for ovarian cysts is an endometrioma. In this condition, menstrual blood collects over the ovary, finally ballooning it into a blood filled sac. This is called an endometrioma and the blood inside the sac is usually old blood.
4. Cancerous cysts: Cancerous cysts usually have solid components besides the usual liquid contents of simple ovarian cysts. These differences could be detected by ultrasonography. A special type of ultrasonography called colour doppler ultrasonography could detect the presence of increased blood flow in the ovary suggestive of malignancy in the ovarian cyst.

Some blood tests like CA125 levels could also be useful in the detection of malignancy.

Q:What are the types of surgeries performed for ovarian cysts?
A: Ovarian cysts could be removed by peeling them off the ovaries by a procedure called cystectomy. Sometimes the ovary is removed along with the cyst. Both these procedures could be done either laparoscopically where there are just 2 or 3 holes in the abdomen and the patient requires very little convalescence, or by open surgery, where the abdomen will have a long cut in it and the patient may have to refrain from lifting heavy weights for a few months.


Questions and Answers compiled by
Dr.Shobhana Mohandas. MD.DGO.FICOG.Dip.Endoscopy.
Consultant Gynaecologist, Sun Medical and Research Centre,
Thrissur, Kerala.
Email: shobhanamohandas@yahoo.co.in.

Urinary problems
Dr.Shobhana Mohandas.MD.DGO.FICOG. Dip.Endoscopy
Sun Medical and Research Centre, Thrissur, Kerala.


Q1 A 70 year old lady gets severe pain during micturition.Pain continues in spite of anti biotics . What could be the cause? What should be done?
Urinary infection is a common reason for getting painful micturition. However, at this age, many other factors need consideration. 1. The opening of the urethra, called urethral meatus, sometimes gets tightly closed at this age. This may be secondary to lack of the hormone oestrogen, following menopause. 2. The nerve supply to the bladder also may be affected at this age weakening the contractions of the urinary bladder. A visit to the urologist is necessary at this stage. A cystoscopy may be necessary. Cystoscopy essentially means insertion of an instrument, into the bladder to see if there are any abnormalities in the urinary bladder. If the urethra is tight, it can be dilated and made large enough for easy passage of urine. Diabetes has to be ruled out. 3. There could be deficiency of the hormone oestrogen in the local tissues, causing pain. This oestrogen deficiency should be treated with local oestrogen preparations.

Q2. A 72 years old lady had, severe pain during urination and a urologist enlarged the urinary opening 2 years back. Now she is beginning to get discomfort during urination. Is there some way she can prevent it from becoming worse?
Using local oestrogen creams can prevent atrophic vaginitis and this may be tried with the help of a gynaecologist.

Q3. A 60 year old woman is unable to control herself when she feels like passing urine.She is taking drugs for it, and she is slightly better. How long will she have to take these drugs? Will there be side effects if they are taken for long?
The inability to control urination is called urge incontinence. This may happen in the later stages of menopause due to deficiciency of hormones. Drugs used to treat this condition may have to be taken for years together.

Q4. A 65 year old woman keeps getting repeated attacks of urinary infection. What could be the cause? Is there something she can do to prevent this?
In the late post menopausal woman, deficiency of the hormone oestrogen could be a factor in causing recurrent urinary tract infections(UTI). Good local hygiene , proper control of diabetes, treatement of incontinence if any could help. Cranberry juice is said to be helpful in these situations.

Q5. I get wet everytime I cough, laugh or sneeze. Is it because of menopause,and what can be done?
Stress urinary incontinence, or SUI is the word used for involuntary passage of urine with increased strain, like coughing, laughing or sneezing. It is not necessarily related to menopause and oestrogen creams may not be enough to cure it. There are exercises which may help control SUI. It should be done in the following way:

Close around the back passage as if you are trying to stop the release of wind. Then close the front passages as if stopping the flow of urine. Lift the passages and hold them for as long as you can, up to a maximum of 10 seconds. Release and rest for a few seconds. Repeat this exercise as many times as you can, to a maximum of 10. While doing the pelvic-floor exercises do not hold your breath, tighten your buttocks or thighs, or pull in your upper abdominal muscles. Do not routinely attempt to stop midstream while passing urine, as this may prevent complete emptying of the bladder and lead to infection. These exercises can be performed in any position, but you should concentrate on doing them correctly and should not do them while engaged in some other activity (e.g. while washing up).

For patients for whom exercises don’t help, using vaginal tampons may be useful as a temporary measure. There are drugs which can help in a few patients, but some patients may feel drowsy while taking them.

The final cure for patients with SUI is surgical. The current surgical modality most frequently practiced by gynaecologists and urologists is the insertion of tension free tapes in front of the urethra. These tapes are made of a particular material. After surgery, the patients generally can go home in a day or two.

Questions and Answers compiled by:
Dr.Shobhana Mohandas. MD.DGO.FICOG.Dip.Endoscopy.
Consultant Gynaecologist, Sun Medical and Research Centre,
Thrissur, Kerala.
Email: shobhanamohandas@yahoo.co.in.
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