The health professional will insert a speculum (a small instrument that opens the vaginal walls) into your vagina and gently take a sample of the cell lining your cervix (the lower or neck part of your uterus).

These cells will then be sent for analysis. In most instances, it will come back as normal. However, it is a screening test and a small percentage of women will have to go for a further test which is called a colposcopy.

COLPOSCOPY

This is when the cervix is viewed with a microscope or a colposcope. Prior to the treatment, your specialist will sit down with you, explain the reason why you are having the procedure done and explain in detail how it will be performed.

You will then be asked to empty your bladder and to get changed. You’ll place your legs in the stirrups and a small speculum will be inserted which allows the specialist to easily view the cervix area.

The specialist will then paint or spray your cervix with a 3% or 5% solution of acetic acid (vinegar). They may also apply an iodine solution called lugol’s iodine. He/she will then look very carefully at the entire area of the cervix and try and find the abnormal areas. Once these have been located a biopsy will be taken. This is a  very tiny sample of the abnormal area. The biopsy should not hurt but may be felt as a pin prick. There is usually some bleeding associated which is easily stopped.

A tampon will be inserted and it’s advisable to keep that in for a few hours.

A follow-up appointment will be made to discuss the results and any proposed treatment.

TREATMENT OPTIONS

If the results come back as a low-grade change then you will probably not require any treatment. However, regular follow up checks will be made to ensure there are no further changes.

If the results come back as a high-grade change then you will need the area to be removed with either a laser, a large electrical loop or with a cold knife. The method of removal will depend on what type of change there is and the extent of the change.

Most lesions can be removed with a Lletz loop (large loop removal) which is a relatively simple procedure and can be done under local or general anesthetic.

A follow up in 6 months will be required.

The post Abnormal Pap Smear Test & Colposcopy appeared first on Gynaecologist Auckland.

This condition may be caused by any number of reasons. The endometrium  (the lining of the uterus)  may become thickened, breaks down resulting in heavy bleeding.

Other causes of heavy bleeding are fibroids, polyps, cervical or endometrial cancer, thyroid disease, hormonal imbalance and local vaginal causes. There remains a large group of women where no identifiable cause can be found. We group these women into a large group called  Dysfunctional Uterine Bleeding or DUB.

How do I know when menstrual bleeding is abnormal?

You may be experiencing abnormal uterine bleeding if you are changing pads and/or tampons more often than one or two hourly or having a period lasting more than 7  days. With the heavy bleeding, you may be passing clots or flooding (when the blood runs down your legs.).Soiling the bed at night may also indicate that bleeding is excessive.

Uterine Bleeding is always abnormal when;

• Bleeding occurs between periods
• Bleeding occurs following sex
• Spotting occurs at any time during the menstrual cycle
• Bleeding is heavier than normal  or lasts for more days than usual
• Bleeding occurs after menopause
• Periods are extremely painful.

What causes abnormal uterine bleeding?

In Adolescents, young women and women approaching menopause abnormal bleeding is usually a result of a hormonal inbalance.They may not be ovulating (producing eggs).

Other causes include;

• Fibroid tumors
• Cervical or endometrial polyps
• Hormonal imbalance
• Cervical cancer
• Endometrial cancer
• Dysfunctional uterine bleeding
• Local vaginal causes.

A single episode of heavy menstrual bleeding usually does not require treatment, however excessive uterine bleeding that continues for over 24 hours does.

Investigations & Treatment

A visit to the doctor will involve a history, examination, swabs and a smear test, blood tests and possibly an ultrasound.

From all information gained, a plan should be drawn up and a treatment plan worked out. The treatment will depend largely on the severity of the condition, the age of the women and her desire for children.

The post Heavy Menstrual Bleeding and Menorrhagia appeared first on Gynaecologist Auckland.

Fibroid tumors are solid tumors which are made of fibrous tissue, hence the name ‘fibroid’ tumor. Most often fibroids occur as multiple tumor masses which are slow-growing and often cause no symptoms.

The size of fibroids varies immensely among women and some are so small that a microscope is required to see them. However, some women experience a single large fibroid tumor the size of a grapefruit or a fibroid which is so large it encompasses the entire abdominal area.

The evidence of why fibroid tumors develop is still not certain, though some facts seem clear:

• fibroid tumors do not develop before the body begins producing estrogen during the onset of menstruation
• fibroid tumors will continue to grow while estrogen is present they will grow very quickly during pregnancy when the body is producing extra estrogen
• the tumors often shrink and disappear after menopause when the body stops producing estrogen
• a woman will almost never develop fibroid tumors after menopause.

The estrogen connection appears to be quite clear, although there are still some who doubt the role estrogen plays in the development of fibroid tumors because women with fibroids often have blood levels which reveal normal amounts of estrogen.

Types of Fibroid Tumors

• Submucous Fibroids
  These fibroids occur just below the lining of the uterus and can cause menstrual problems, including pain as they grow and move around the pelvic area.
• Intramural Fibroids
  A round fibroid most often within the uterine wall which can cause enlargement of the uterus as they grow.
• Subserous Fibroids
  This fibroid grows on the outer wall of the uterus and usually causes no symptoms until it grows large enough to interfere with other organs.
• Pedunculated Fibroids
  These fibroids develop when a subserous fibroid grows a peduncle (stalk), as they grow larger they may become twisted and cause severe pain.
• Interligamentous Fibroid
  A fibroid which grows sideways between the ligaments which support the uterus in the abdominal region. This type of fibroid is especially difficult to remove without the possibility of interfering with the blood supply or other organs.
• Parasitic Fibroid
  The rarest form of fibroid tumor occurs when a fibroid attaches itself to another organ.

Diagnosis of Fibroid Tumors

Diagnosis of fibroids is generally made by your physician during your annual gynecological exam when your physician feels a mass, they often are found when your physician is looking for something else or may never be discovered if you do not experience symptoms. However larger fibroids may make the examination of your ovaries impossible if they grow near your ovaries.

An ultrasound scan is often ordered when such masses are felt by your physician to determine the cause of the mass, however, some fibroids appear on sonograms as ovarian tumors and surgery is the only way an accurate diagnosis can be made.

Although most fibroids cause no symptoms, the estimated 25 percent of women who do have symptoms may have abnormal bleeding, pain during menstruation, and as the fibroid tumors grow larger, women will often experience a swollen abdomen.

Larger fibroids may cause frequent urination or an inability to control your bladder, either the ability to control the urge or in severe cases, a women may find that she is unable to urinate at all. If a fibroid extends towards a woman’s back it may push on the bowels, causing constipation and a backache.

Treatment

Often nothing is required other than watching with regular checkups. If they are large and/or causing symptoms such as bleeding or pain they will need to be removed surgically either as a hysterectomy (removal of the uterus) or a myomectomy (removal of the fibroid). Embolisation (blocking the blood supply to the fibroid) can also be done in selective cases. This can sometimes shrink them.

The post What are Uterine Fibroid Tumors appeared first on Gynaecologist Auckland.

A hysterectomy is the surgical removal of the uterus (womb).  Most hysterectomies are performed for non-cancerous problems such as heavy bleeding, pain, and discomfort.

The most common reasons we would do a hysterectomy are:

1. Uterine fibroids. These are benign growths of the muscle of the uterus. These can cause pain, bleeding, pressure on the bladder or bowel, and an abdominal mass.
2. Prolapse of the uterus. Weakness of the pelvic floor muscles can cause the uterus and the walls of the vagina to prolapsed or come out through the vagina.
3. Heavy or irregular bleeding. Often this is unexplained and fits into the group of conditions called Dysfunctional Uterine Bleeding or D.U.B.
4. Adenomyosis or endometriosis of the uterus. This is when the lining of the uterus migrates into the uterine muscle and may cause:
   – Abdominal pain
   – Heavy bleeding
   – Painful intercourse
   -Very painful periods
   – Uterine tenderness.

What kinds of Hysterectomies are there?

1. Total Hysterectomy: This is when the uterus and the cervix (lower part of the uterus) are removed.
2. Total Hysterectomy plus unilateral (one) or bilateral salpingo-oophorectomy (both). What this means is the total hysterectomy plus one or both ovaries and fallopian tubes.
3. Subtotal hysterectomy with or without ovaries and tubes. This is when the uterus is removed but not the cervix.
4. Radical Hysterectomy. This is usually done for cancer and is when the uterus, top of the vagina and the tissue around the cervix is removed. The ovaries and fallopian tubes may or may not be removed.

There are different ways to perform this operation which your surgeon will discuss with you.  Your choice will depend on the reason for the surgery and what your surgeon is most comfortable doing.

There are three groups of procedures:

1. Abdominal Hysterectomy; an incision is made into the tummy and the operation is done through an abdominal wound.
2. Vaginal Hysterectomy: The operation is done through the vagina.
3. Laparoscopic Hysterectomy; This is when the operation is done through a telescope and is referred to as minimally invasive surgery.  Always remember that although the skin incisions are small the internal surgery is the same major surgery.

All the operations have pros and cons and it is really up to you and your surgeon as to which type of hysterectomy is most appropriate for you.

The Subtotal Hysterectomy

This is when the tummy is opened or it can be done laparoscopically but not vaginally. The uterus is removed but the cervix is left untouched meaning that the vagina does not need to be opened.

This is the most common type of surgery I perform and one which many women are requesting. This type of surgery is particular for benign conditions such as fibroids which is my special interest.

Many women feel that their cervix is an integral part of their sexual fulfillment and would prefer the vagina not to be opened from above and have it disturbed. I have also found less postoperative bleeding and less post-operative complications related to this surgery. The recovery time seems to be quicker, the problem is resolved and as much of the anatomy is left intact. Hospital stay is also usually reduced.

Of course, the smears should be normal and it is very important to remember that you should continue to have ongoing smear tests as you normally would.

The hospital stay for hysterectomy is about 3 to 5 days depending on the person, type of operation and whether there have been any complications. The off work period is usually 4–6 weeks.

Please always remember that a hysterectomy is a major surgery and as with any surgery there can always be complications. This needs to be discussed with your doctor and explained to you in detail.

The post Hysterectomy Treatments appeared first on Gynaecologist Auckland.

What is the menopause?

The menopause signals a time of change in a woman’s life hence the common term “change of life”. It is when ovulation ceases and periods stop. The ovaries in effect stop producing eggs and most of their hormones mainly oestogen but also progesterone and testosterone.  Fertility ceases and therefore she no longer needs to consider contraception.

For a large number of women, this change happens with very little ill effects and they happily enter a more carefree and exciting phase in their lives. However, for a group of women, this phase becomes extremely uncomfortable and very distressing. It is this group that we as gynaecologists see and help.

The average age of menopause is approximately 52 but the normal range is between 45 and 60. If it is before 40 it is called ‘premature menopause’ and that has a number of problems on its own.

Briefly,  premature menopause or premature ovarian failure often has no known cause. It may be a genetic problem, as part of an overall gland failure or surgically induced when the ovaries are removed either by surgery or destroyed by radiotherapy or chemotherapy.

The symptoms of menopause

1. Change in the menstrual cycle: Periods may suddenly disappear or become irregular lighter or heavier. Everybody is different
2. Hot flushes:  This is one of the most common symptoms of menopause and the most distressing. These are characterized by a feeling of intense heat that usually begins around the face and neck causing a flush. The face is red and may be sweaty. The heat then moves to the rest of the body. It can last from a few seconds to many minutes. They are common at night and there can be several during this time resulting in sleep deprivation and exhaustion. They may also be accompanied by general sweating, nausea, tiredness and heart palpitations.
3. Vaginal Dryness: I find this to be the most complained about long-term symptom. As with the mouth the vagina needs to be comfortably moist at all times. The vaginal mucosa (skin) is extremely sensitive to hormones so when they disappear the skin becomes thin, less elastic, dry, irritating, and sore and becomes susceptible to infections such as thrush. Intercourse becomes dry and uncomfortable with pain, bleeding and difficulty with penetration.
4. Urinary symptoms:  Many women complain of frequency, waking up at night to pass urine, urgency and leaking when coughing, sneezing or laughing. These symptoms are because of a lack of hormone acting on the urinary tract.
5. Mood swings and other emotional problems:  Hormone lack can exacerbate other life problems such as domestic issues, aging, children and relationship issues.
6. Sexual issues: In some women, there is a marked change in their sexuality around the menopause. Feelings and desires may change. Intercourse can be dry and uncomfortable. Tiredness due to sleep disturbances can further decrease her desire. The aging process and related body image issues can all lead to a loss of desire.  Low or absent Oestrogen, progesterone and testosterone levels can all reduce one’s libido.
7. Other less obvious changes: Dry skin, itchy crawly skin, coarse hair growth, weight gain, aching joints, and muscles can all occur.

Management of the menopause

The first thing I do when I see a woman with menopausal symptoms is listen. I take a full and detailed history going into detail of all her symptoms. I also go into detail about general health issues.

I then do a full and detailed physical examination including a smear test and a vaginal swab. I then do an internal vaginal examination paying particular attention to the vaginal skin, the wall of the vagina (looking for prolapsed), and the internal vaginal organs such as the uterus and ovaries.

I then order some blood tests which include lipids (cholesterol), full blood count, liver, and kidney function tests and hormone tests.

If indicated I order a pelvic ultrasound and a bone density examination (to rule out osteoporosis).

I then see her again, collate all these results and then work out a management plan with her.

Treatment of the menopause

For a large number of women simple advice, reassurance of normality and support is all that is required.

There are however those women who will need HRT or hormone replacement therapy. This is where the controversy exists. The popular media and certain interest groups have condemned the use of HRT.I believe very strongly that where the indication exists and as long as the risks and benefits are fully discussed and understood there is definitely a place for HRT in the treatment of menopause.

HRT can alleviate hot flushes, vaginal dryness, low sex drive, urinary symptoms, sleep disturbances and a multitude of symptoms that make the menopause a miserable time for the woman, her partner, and her family.

HRT can be given as pills, patches, implants and/or a vaginal cream or pessaries.

The best thing to do is discuss these issues with your doctor and together work out whether HRT is appropriate for you and if so what the best way of delivering the hormone is.

The post Menopause Symptoms and Treatment appeared first on Gynaecologist Auckland.

As always with such a diverse group of people, there were so many options and such a variety of options that people can follow.

Let me spend a few minutes going over what we mean by the different term we use to define incontinence. I will stick to urinary incontinence and not faecal incontinence.

Urinary Incontinence is the involuntary passage of urine.

1) Urinary Stress incontinence or USI: This is the involuntary passage of urine when there is an increase in intra abdominal pressure such as coughing sneezing or laughing. This is extremely common; in fact, almost all women may at some point in their lives experience this. The causes are often related to childbirth and vaginal prolapsed. During childbirth, the pelvic floor muscles are often damaged resulting often in a prolapse. As one gets older and the hormones change this will further aggravate the situation. Last but by no means is least what you inherit from your mum, aunts, and grandmother.

If it is a minor irritant and occasional it best to follow the conservative approach which involves pelvic floor exercise alone or under the guidance of a physiotherapist. If it is of such a problem that you need to constantly wear pads and it adversely affects your life then surgery may be the answer.

2) Urgency and urge incontinence UI: The woman who always knows where the nearest toilet is is probably suffering from urgency. This is the need to go feeling and if you can’t make you will wet. It is the urgent desire to pass urine often small amount.

The commonest cause is cystitis or bladder infection. However, it also occurs in older women who lack oestrogen or hormone support of their vaginas. Other causes are neurological disease, tumours, small capacity bladders and a condition called interstitial cystitis.

This is an extremely debilitating condition and should always be medically addressed.

3) Overflow incontinence: the bladder overfills, the desire to empty is not felt or there is an obstruction to the outflow and the bladder gets overfull. Causes are neurological or obstructive.

Often the incontinence is mixed and has components of one two or three.

With each of these types, there are specific treatments most of which are extremely successful.

Often a test called urodynamics is performed. These are pressure testing where we would be able to determine which incontinence you have and then the correct treatment can be offered.

Talk to your healthcare professional about this. It is often embarrassing but there is help at hand which as I say is usually excellent

The post Urinary Incontinence, Urgency & Stress appeared first on Gynaecologist Auckland.

Often the awareness is made at a routine scan when the fetal heart is not seen to be beating.

Sometimes this is preceded by a brownish discharge or some abdominal cramping.

One of the most important signs is that the woman no longer feels pregnant.

A very important fact is that usually the woman has done or could have done absolutely nothing to cause the death of her foetus. The pregnancy is a bad one very often a severe chromosomal abnormality and by natural selection has died.

The big debate is what to do next. Should one undergo a surgical evacuation or wait for nature to take its course. We as gynaecologist’s more often than not opt for the surgical emptying of the uterus. The operation is relatively safe (although complication may occur) and it finalizes the event so one can move on. The other advantage is that there is much less risk of infection.

The operation is usually done under general anesthesia and takes about 15 minutes to do. After the procedure, there may be some bleeding and cramping bet that settles fairly quickly.

Afterward, your doctor would probably want to see you. I call it a “debriefing” where we discuss the operation, the outcome, possible causes and most importantly what about the next time.

My plan that I propose and very often do is as follows:

1. One can try again whenever. There is very little evidence to show that waiting is of any benefit at all. In fact, recent evidence shows the sooner the better.
2. Once the pregnancy is suspected an early HCG (pregnancy hormone) blood test should be done.
3. If this is positive then I like to do these twice weekly on a Monday and a Thursday. They should approximately double every 2 and half days until the level plateaus.
4. I then do a six week scan to try and see a fetal heart.
5. As many scans as indicated until we are sure that all is well

Remember that this plan does not improve outcome but does give us peace of mind and will alert us early on if things are going wrong.

More often than not the cause of the miscarriage is never found.

If one has had 3 or more consecutive miscarriages we call this a habitual abortion and we would then instate a number of tests to try and identify the cause.

The post Early Pregnancy Loss & a Plan for Follow Up appeared first on Gynaecologist Auckland.

Of course, this came as a huge shock to her. As I always do I explained everything to here is detail including drawings, alternative options and gave her printed information. She went home, did some ‘googling’, spoke with friends and her husband and came back for her second visit together with her husband.

She was armed with a long list of questions and comments. I welcome this and we spent well over half an hour going through her issues and concerns. I thought afterward how wonderful that interview was for her as now she is fully informed and if she decides to go ahead the consent she signs will be an informed consent.

I often ask people “Do you have any questions ?” They reply “I don’t know what to ask!” So here are a few pertinent questions you may want to know from your surgeon.

1. Do I really need to have the surgery? What are the indications?
2. Are there  any alternative treatments available especially non-surgical ones
3. How urgent is this surgery and can it wait?
4. What are the risks associated with the procedure
5. What risks do I face if I don’t have the surgery
6. What risks do I face if I delay the surgery?
7. How many of these procedures has the surgeon done
8. What is his/her complication rate
9. How long will the procedure be
10. How long will I be in hospital?
11. Do you have access to other surgeons such as general bowel surgeons, urologists or other gynaecologists in case they are needed during my operation? If so who are they?
12. Who is your anesthetist and can I talk with him/her prior to the surgery
13. What is my recovery time and when can I go back to work.
14. When can I resume household activities?
15. When can I resume sexual activity?
16. How can I get hold of you if I have a problem post-operatively?
17. Do you see me in hospital after the surgery and will you see me every day
18. Can you talk to my husband/partner/children or nominated person post op
19. When will you see me for a follow-up?
20. How much is the surgery and can I expect surprises in costing.
21. How does he/she feel about a second opinion and if so who would they recommend?

What I have listed is a general help. By asking these questions (and of course any others you may think of) you should have a very good idea of what you are in for. Naturally, your surgeon should explain what they intend to do in absolute detail in a language that you fully understand. Always remember you have a choice as to whether you want the procedure and who will do it. Armed with all the information your choice becomes informed and that is your empowerment.

The post Gynaecologist – What You Should Know And Ask Before Surgery appeared first on Gynaecologist Auckland.

The medical term for painful intercourse is Dyspareunia. It can be divided into two;

1. Superficial which is mainly outer and inner vagina but not to the deepest part
2. Deep dyspareunia which is pain deep in the pelvis and lower abdomen.

Let’s talk about each one in a bit more detail.

Superficial Dyspareunia
This is an extremely common complaint. The most common cause is thrush or other vaginal infections. Anything that impedes penetration such as scar tissue (from birth tears), an entry that is too narrow, painful hymenal tags, imperforate hymen, vaginal prolapse, or cysts or growths in the vagina can cause pain.

In older women and sometimes in younger ones vaginal dryness can cause pain and discomfort.

The treatment will obviously depend on the cause. Almost always these can be remedied with either medication or relatively simple surgery.

The most important thing is not to leave it. Get it sorted as soon as possible.

Deep Dyspareunia
The pain is deep in the pelvis or lower abdomen. The commonest reason is a retroverted uterus. This is when the uterus is facing downwards and is being “ hit “ directly. About 20% of uteruses face downwards and this normal. A change in positions is all that is needed to overcome this problem.

Other more serious problems such as endometriosis, adenomyosis (endometriosis of the uterus), ovarian cysts or pelvic infection (both acute and chronic) can all cause painful intercourse.

The most important message is don’t leave it. If sex has always been painful from the beginning you should address it. Relationships can be adversely affected and there is almost always a solution. If sex has been fine and then becomes painful especially deep, then attention is more urgently needed.

Seek help. The issue is extremely personal and private, so choose somebody who you can talk and relate to. That person could be your G.P. or specialist. Be honest and frank however embarrassing you may find it. THERE IS ALMOST ALWAYS A REMEDIAL ANSWER.

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It is always fascinating to see that we all have similar problems with certain conditions. The standard of general practice in New Zealand is extremely high so when they have a problem you can be sure it is challenging for me to provide an adequate answer.

One of the most taxing day to day problems is that of a “Chemical Pregnancy”.

Now, what does that mean? In essence, it is a very early pregnancy.

When fertilization takes place the fertilized egg then makes it way down the fallopian tube into the uterus. Once there it implants and stars producing a hormone Human Chorionic Hormone or HCG. This can then be measured. Technology is so good now that even the most minute amounts are measurable. This is where we run into trouble. The test becomes positive and is quantitated early on when the levels are very low. Sometimes just too early. This is what is understood as being a chemical pregnancy.

As we know a large number of pregnancies fail and these very early ones fail the most. Often the HCG is measured even before a period is missed.

So one can understand the disappointment and frustration that emerges when in fact the pregnancy was doomed to fail anyway and if one waited for just a wee while longer then a period would ensue and we would all be none the wiser.

I don’t quite know what the answer is other than when an HCG is measured that early on one should be prepared for the possibility of a pregnancy failure.

As pregnancy is a dynamic event if one wants to know the pattern of progress HCG testing should be done about twice a week. Normally the level should double every 2 and a bit days until a level of somewhere around 30,000 is reached and then it plateaus or may even fall. By this time, however, a fetal heartbeat should be detected on ultrasound. If the pattern is not going up appropriately then the pregnancy may fail.

The HCG measurements do not obviously improve outcome but definitely, give us guidance as to how it is progressing until such time that the fetal heartbeat is seen ( somewhere around 6 to 6  and a half weeks.)

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