Common Conditions

An overview of the most common conditions that are treated by The Gynaecology Group are detailed below. For information about any additional gynaecological conditions not featured within the site, please contact us for more information.

ADHESIONS

Adhesions are fibrous bands that can limit the normal movement of organs within the abdominal and pelvic cavities. They can occur after any abdominal surgery or pelvic/abdominal infections and may cause pelvic pain.

Adhesions can only be diagnosed during a laparoscopy and can be treated at the same time.

ECTOPIC PREGNANCY

What is an ectopic pregnancy?

An ectopic pregnancy is when a pregnancy starts to grow outside the uterus (womb). In the UK, one in 90 (just over 1%) pregnancies is an ectopic pregnancy.

When you become pregnant, the sperm and egg meet in the fallopian tube (the tube that carries the egg from the ovary to the uterus). Usually, the fertilised egg moves into the uterus for the pregnancy to grow and develop. If this does not happen, an ectopic pregnancy may start to develop in a fallopian tube (sometimes known as a tubal pregnancy). An ectopic pregnancy can occur in places other than a fallopian tube, such as in the ovary (rarely) or inside the abdomen (very rarely).

This information is about an ectopic pregnancy in the fallopian tube. A pregnancy cannot survive in this situation and – sadly – cannot lead to the birth of a baby. This is because as the pregnancy gets bigger it can:

 run out of space to grow in the fallopian tube
 rupture (burst) the fallopian tube, causing severe pain and internal bleeding. This is a potentially life-threatening situation for you.



What are the symptoms of an ectopic pregnancy?

Most women get physical symptoms in the sixth week of pregnancy – about two weeks after a missed period. You may or may not be aware you are pregnant if your periods are irregular or if the contraception you are using has failed. Each woman is affected differently by an ectopic pregnancy. Some women have no symptoms, some have a few symptoms while others have many symptoms.

Because symptoms vary so much, it is not always straightforward to make a diagnosis of an ectopic pregnancy. The symptoms of an ectopic pregnancy may include:

Abnormal bleeding
You may have some spotting or bleeding that is different from your normal period. The bleeding may be lighter or heavier than normal. The blood may be darker and more watery.

Pain in your lower abdomen
This may develop suddenly for no apparent reason or may come on gradually over several days. It may be on one side only.

Pain in the tip of your shoulder
This occurs due to blood leaking into the abdomen. This pain is there all the time and may be worse when you are lying down. It is not helped by movement and may not be relieved by painkillers.

Upset tummy
You may have diarrhoea or pain on opening your bowels.

Severe pain/collapse
If the fallopian tube ruptures and causes internal bleeding, you may develop intense pain or you may collapse. This is an emergency situation. In rare instances, collapse is the first sign of an ectopic pregnancy.

Should I seek medical advice immediately?

Yes! An ectopic pregnancy can pose a serious risk to your health. If you have had sex within the last 3 to 4 months (even if you have used contraception) and are experiencing these symptoms, get medical help immediately. Seek advice even if you do not think you could be pregnant.

Am I at increased risk of an ectopic pregnancy?

Any woman of childbearing age who is having sex could have an ectopic pregnancy. You are at an increased risk of an ectopic pregnancy if:

 you have had a previous ectopic pregnancy
 you have a damaged fallopian tube. The main causes of damage are:
o previous surgery to your fallopian tubes, including sterilisation
o previous infection in your fallopian tubes
 you become pregnant when you have an intrauterine device (IUD/coil) or if you are on the progesterone-only contraceptive pill (mini-pill)
 your pregnancy is an in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) pregnancy
 you are over 40 years old
 you smoke.

How do I get a diagnosis?

Most ectopic pregnancies are suspected between 6 and 10 weeks of pregnancy. Sometimes the diagnosis is made quickly, but if you are in the early stages of pregnancy, it can take longer (a week or more) to make a diagnosis of an ectopic pregnancy.

Your diagnosis will be confirmed by the following:

Consultation and examination
The doctor will ask about your medical history and symptoms. The doctor will examine your abdomen and may also do a vaginal (internal) examination. You should be offered a female chaperone (someone to accompany you) for this. You may also wish to bring someone to support you during your examination.

If you have not already had a positive pregnancy test, you will be asked for a urine sample so this can be tested for pregnancy. If the pregnancy test is negative, it is very unlikely that your symptoms are due to an ectopic pregnancy.

Ultrasound scan
Most women are offered a transvaginal scan (where a probe is gently inserted into your vagina) to look at the uterus, ovaries and fallopian tubes. If you are in the early stages of pregnancy, you may be offered another scan after a few days when it may be easier to see the pregnancy.

Blood tests
 A test for the level of the pregnancy hormone human chorionic gonadotrophin (hCG) or a change in this level every few days may help to give a diagnosis.
 A test for the level of the hormone progesterone may be taken.

Laparoscopy

If the diagnosis is still unclear, an operation called a laparoscopy may be necessary. This operation takes place under a general anaesthetic. The doctor uses a small telescope to look at your pelvis by making a tiny cut usually into the umbilicus (tummy button). This is also called keyhole surgery.
If an ectopic pregnancy is detected, treatment may take place during the same operation.

What are the options for treatment?

Because an ectopic pregnancy cannot lead to the birth of a baby, all options end the pregnancy in order to reduce the risks to your own health. Your options depend on:

 how many weeks pregnant you are  your symptoms
 if there has been a lot of bleeding inside your abdomen
 the level of hCG your scan result
 your general health
 your personal views and preferences – this should involve a discussion about your future pregnancy plans
 the options available at your local hospital. The options for treatment are listed below – not all will be suitable for you.

Expectant management (wait and see)

Ectopic pregnancies sometimes end on their own – similar to a miscarriage. Depending on your situation, it may be possible to monitor the hCG levels with blood tests every few days until these are back to normal. Although you do not have to stay in hospital, you should go back to hospital if you get any symptoms.

Expectant management is not an option for all women. It is usually only possible when the pregnancy is still in the early stages and when you have a few or no symptoms. Up to 29 in 100 (29%) women undergoing expectant management may require additional medical or surgical management.

Medical treatment

In certain circumstances, an ectopic pregnancy may be treated by medication (drugs). The fallopian tube is not removed. A drug (methotrexate) prevents the pregnancy from developing and so the ectopic pregnancy gradually disappears.

The drug is given as an injection. If your pregnancy is beyond the very early stages or the hCG level is high, methotrexate is less likely to succeed. Many women experience some pain in the first few days, but this usually settles with paracetamol or similar pain relief. Although long-term treatment with methotrexate for otherillnesses can cause significant side effects, this is rarely the case with one or two injections to treat ectopic pregnancy.

You may need to stay in hospital overnight and then return to the clinic or ward a few days later. It may be sooner if you have any symptoms. It is very important that you attend your follow-up appointments.
 Fifteen in 100 (15%) women need to have a second injection of methotrexate.
 Seven in 100 (7%) women will need surgery, even after medical treatment.

Surgery

The aim of surgery is to remove the ectopic pregnancy. The type of operation you have will depend on your wishes or plans for a future pregnancy and what your surgeon finds during the operation (laparoscopy).

To have the best chance of a future pregnancy inside your uterus, and to reduce the risk of having another ectopic pregnancy, you will usually be advised to have your fallopian tube removed (salpingectomy).

If you only have one tube or your other tube does not look healthy, this already affects your chances of getting pregnant. In this circumstance, you may be advised to have a different operation (salpingotomy). This operation aims to remove the pregnancy without removing the tube. It carries a higher risk of a future ectopic pregnancy but means you retain the possibility of a pregnancy in the uterus in the future. Some women may need to have a further operation to remove the tube later if the pregnancy has not been completely removed.

An operation to remove the ectopic pregnancy will involve a general anaesthetic.

The surgery will be via a laparoscopy – the stay in hospital is about 1 to 2 days and the recovery is about 2 to 4 weeks. There are risks associated with any operation. This may be due to the use of an anaesthetic or the operation itself. Your surgeon and anaesthetist will discuss these with you.

What do I need to know to make an informed decision?

When an ectopic pregnancy is confirmed, and if the fallopian tube has not ruptured, your doctor should discuss your options with you.

Make sure you:

 fully understand all your options
 ask for more information if there is something you do not understand
 raise your concerns
 understand what each option means for your fertility
 have enough time to make your decision.

In an emergency situation

If the fallopian tube has ruptured, emergency surgery is needed to stop the bleeding. This is achieved by removing the ruptured fallopian tube and pregnancy.

This operation is often life-saving. Your doctors will need to act quickly and this may mean that they have to make a decision on your behalf to operate. In this situation you may need a blood transfusion.

Follow-up appointments: what happens next?

It is important that you attend your follow-up appointments. The check-ups and tests you have will depend on the treatment you received.

Expectant management

Your doctor will need to check your blood levels of hCG every few days until normal levels are reached. This is to ensure that the pregnancy has completely ended. You may need further ultrasound scans.

Medical management

You will need to return twice in the first week and then once a week to check your blood levels of hCG. It may take a few weeks to ensure the pregnancy has completely ended and you may need further ultrasound scans. During this time, you should not have sex. You should avoid getting pregnant by using reliable contraception for at least 3 months.

Surgical management

You may be offered a follow-up appointment with your gynaecologist, particularly if you have had an emergency operation. If you have not had your fallopian tube removed, you will need to have your hCG level checked until this is back to normal.

What about future pregnancies?

For most women an ectopic pregnancy occurs as a ‘one off’ event and does not occur again. The chance of having a successful pregnancy in the future is good.

Even if you have only one fallopian tube, your chance of conceiving is only slightly reduced. The overall chance of having an ectopic pregnancy next time is between 7 and 10 in 100 (7–10%). However, this depends on the type of surgery you had and any underlying damage to the remaining tube(s).

In a future pregnancy, you may be offered an ultrasound scan at 6 to 8 weeks to confirm that the pregnancy is developing in the womb.

If you do not want to become pregnant, seek further advice from your doctor or family planning clinic as some forms of contraception may be more suitable after an ectopic pregnancy.

How will I feel afterwards?

The impact of an ectopic pregnancy can be very significant. It can mean coming to terms with the loss of a baby, with the potential impact on future fertility or with the fact you could have lost your life. Each woman copes in her own way – an ectopic pregnancy is a very personal experience. This experience may affect your partner and others in your family as well as close friends.

It is important to remember that the pregnancy could not have continued without causing a serious risk to your health. Before trying for another baby, it is important to wait until you feel ready emotionally and physically.

However traumatic your experience of an ectopic pregnancy has been, it may help to know that the possibility of a normal pregnancy next time is much greater than the possibility of having another ectopic pregnancy. If you have any questions, make sure you speak with your gynaecologist.

ENDOMETRIOSIS / PELVIC PAIN

Endometriosis is the presence of endometrium (lining of the womb) outside the womb. It affects approximately 10% of women and can cause pelvic pain, painful periods, pain with intercourse, pain with passing urine or opening bowels as well as numerous other symptoms. The only way to diagnose endometriosis is by laparoscopy at which time it can generally be removed using fine laparoscopic instruments.

Medical treatment is often effective in reducing pain but recurrence is highly likely without surgical intervention. Removing endometriosis surgically has been shown to reduce pain in more than 60% of women at 5 years and increases fertility rate.

FERTILITY ASSESSMENT

Approximately 10% of couples will have some difficulty conceiving. ‘Fertility assessment’ looks at the common causes of such difficulties i.e. blocked fallopian tubes, presence of endometriosis, non-ovulation or semen abnormalities. Initial investigations include blood tests to check ovulation, semen analysis, a check for previous pelvic infection and a laparoscopy and ‘dye hydrotubation’ (passing dye through the fallopian tubes to check their patency). A hysteroscopy may also be required (looking inside the uterus with a fine telescope) to exclude the presence of fibroids or polyps.

As a group of specialists we offer rapid investigation and treatment of the common underlying causes of female subfertility i.e. endometriosis, adhesions, fibroids, polycystic ovaries (PCOS) and endometrial polyps.

FIBROIDS

Fibroids are benign (non-cancerous) muscle growths of the womb that affect more than 25% of women.

Symptoms:

heavy periods
abdominal bloating/discomfort
difficulty conceiving
pelvic/abdominal or back pain
pain with intercourse
bladder and bowel pressure symptoms

Diagnosis

They are usually diagnosed with ultrasound or hysteroscopy

Treatment

Fibroids only need to be treated if they are causing significant symptoms.

Medical treatments can be effective in reducing their size. If they are mainly inside the womb they can be removed hysteroscopically via the cervix without abdominal incisions. If they are mainly on the outside of the womb and fertility is important they can be removed by a laparoscopic or open approach. If fertility is not important then a hysterectomy is curative.

Other techniques can also be used such as uterine artery embolisation.

HEAVY OR PAINFUL PERIODS

Heavy Periods

Heavy periods, also called menorrhagia, is when a woman loses an excessive amount of blood during consecutive periods. Menorrhagia can occur by itself or in combination with other symptoms, such as menstrual pain (dysmenorrhoea).

Heavy bleeding does not necessarily mean there is anything seriously wrong, but it can affect a woman physically, emotionally and socially, and can cause disruption to everyday life.

Painful Periods

Most women experience period pain at some point in their lives.

Period pain – or dysmenorrhoea – is usually felt as painful muscle cramps in the lower tummy, which can sometimes spread to the back and thighs. Sometimes the pain comes in intense spasms, while at other times the pain may be dull but more constant. The pain usually starts when your bleeding begins, and normally lasts for 48-72 hours.

Why it Happens

Most cases of period pain occur when the muscular wall of the womb contracts and presses against nearby blood vessels, briefly cutting off the oxygen supply to the womb and triggering pain.

Occasionally, period pain can be caused by an underlying medical condition, such as endometriosis or pelvic inflammatory disease. This is known as secondary dysmenorrhoea.

How Common Is It?

Period pain is extremely common. Some studies suggest up to 90% of menstruating women experience pain and discomfort during their period.

It’s difficult to categorise period pain as it can affect every woman differently. But one study of more than 400 women with period pain found symptoms were moderately painful in around 20% of women, and severe in 2% of cases.

In another study, up to 14% of women reported frequently being unable to go to work because of period pain.

However, period pain that isn’t caused by an underlying condition tends to improve as you get older. Many women also notice an improvement after they have had children.

INCONTIENCE AND PROLAPSE

Urinary incontinence is the unintentional leaking of urine. Stress incontinence is when you suddenly leak urine because of an increase of pressure on your bladder. This could be from sneezing, coughing or lifting something heavy.

Stress incontinence is often referred to as bladder weakness or weak bladder. It’s the most common type of incontinence. It can affect women and men of any ages but it’s more common among women – approximately one third of women in the UK have stress incontinence.

Other types of urinary incontinence include the following.

 Urge incontinence – this is when you have a sudden and intense urge to pass urine that is usually followed by an unintentional leakage of urine.
 Mixed urinary incontinence – when you unintentionally pass urine because of both stress and urge incontinence.
 Overflow incontinence (also known as chronic urinary retention) – this happens when your bladder doesn’t empty properly, causing urine in it to spill out. It can be caused by weak bladder muscles or a blocked urethra (the tube that carries urine from your bladder out of your body). Overflow incontinence is rare in women.

Some people with severe stress incontinence have constant urine loss (also known as total incontinence). This usually occurs because the urethral sphincter (a group of muscles that surrounds your urethra and keeps urine in your bladder) doesn’t close properly.

MISCARRIAGES

A miscarriage is the loss of a pregnancy that happens sometime during the first 23 weeks. Around three quarters of miscarriages happen during the first 12 weeks of pregnancy (the first trimester).

The main symptom of a miscarriage is vaginal bleeding, which may be followed by cramping and pain in your lower abdomen. If you have vaginal bleeding, contact your local NHS hospital or the Nuffield Private Hospital, Cheltenham. While a miscarriage does not usually seriously affect a woman’s physical health, it can have a significant emotional impact. Many couples experience feelings of loss and grief.

For most women, a miscarriage is a one-off event and they go on to have a successful pregnancy in the future.

What causes a miscarriage?

It is thought that two thirds of early miscarriages are due to abnormal chromosomes in the baby. Chromosomes are genetic “building blocks” that guide the development of a baby. If a baby has too many or not enough chromosomes, the pregnancy can end in miscarriage.

In later miscarriages, a problem with the womb or cervix (neck of the womb) may be the cause.

How common are miscarriages?

Miscarriages are much more common than most people realise. This may be because many women who have had a miscarriage prefer not to talk about it.

Among women who know they are pregnant, it is estimated that 12% of these pregnancies will end in miscarriage. This is around one in eight pregnancies. Many more miscarriages occur before a woman is even aware that she has become pregnant.

Losing three or more pregnancies in a row (recurrent miscarriages) is uncommon and affects around 1 in 100 women. Even in cases of recurrent miscarriages, an estimated three quarters of women go on to have a successful pregnancy in the future.

Treating miscarriage

Your treatment for a miscarriage depends on whether there is any foetal tissue left in your womb (a complete or incomplete miscarriage).

Complete miscarriage

If there is no foetal tissue left in your womb (a complete miscarriage), no further medical treatment is required. However, a miscarriage can have a significant emotional effect and you and your partner may need counselling or support.

Incomplete miscarriage

If there is foetal tissue left in your womb (an incomplete miscarriage), this needs to be removed as there is a risk that it could become infected. This can be done in three ways:

 using minor surgery to remove the tissue
 using medication to remove the tissue
 waiting for the tissue to pass naturally out of your womb (expectant management)

There are benefits and risks of each option that you should consider when making your decision.

If you have surgery, any bleeding or pain you are experiencing because of your miscarriage should quickly improve. However, all surgical procedures carry their own risks. Medication avoids the need for surgery but can cause increased pain and bleeding. Waiting for the tissue to pass naturally avoids taking medication or having surgery, but can take several weeks. It is also possible that not all of the tissue will be removed, and that you will later require surgery.

Discuss the options with your gynaecologist. Surgery Surgery usually takes place within a few days of a miscarriage. However, there are circumstances where you may be advised to have immediate surgery, including:

 if you experience continuous heavy bleeding
 if there is evidence that the foetal tissue has become infected
 if medication or waiting for the tissue to pass out naturally have been unsuccessful

Surgery is usually performed under general anaesthetic. Your cervix (neck of the womb) will be opened with a small tube, known as a dilator, and the tissue will be removed using a suction device. This type of surgery is known as evacuation of retained products of conception (ERPC).

Before surgery, you may be given medication to soften the cervix and to make it easier to perform the surgery. This type of surgery is usually very safe. However, as with all surgery, there is a small risk of complications.

Possible complications include:

 infection
 excessive bleeding
 the womb or cervix being torn during the procedure: this may require further surgery to repair it

Around 2 in 100 women will experience a serious complication, such as a tear to their womb or cervix.

Medication

Using medication to remove the tissue involves taking tablets that cause the cervix to open, allowing the tissue to pass out. There are two types of tablets:

 tablets that you swallow
 tablets called pessaries that are inserted directly into your vagina, where they dissolve

The effects of the tablets usually begin within a few hours. You will experience symptoms similar to a heavy period, such as cramping and heavy vaginal bleeding. You may also experience vaginal bleeding for up to three weeks. Medication is successful in removing foetal tissue in around 9 out of 10 cases. However, you will need to have surgery if the medication is unsuccessful.

Waiting method

If you wait for the tissue to pass naturally out of your womb, it may be some time before you experience vaginal bleeding. This tends to be heavier than your usual period and you may also experience cramping. Bleeding can last for up to three weeks. If the bleeding becomes particularly heavy or you experience severe pain, contact your hospital. You should be given a 24-hour helpline number to call in case of emergency. For more than half of miscarriages, this method is unsuccessful in removing foetal tissue. In this situation, you will need either medication or surgery.

After a miscarriage

You can discuss with your gynaceologist what, if anything, you would like to do after your miscarriage. It is possible to arrange a memorial and burial service. In some hospitals or clinics, it may be possible to arrange a burial within the grounds. You can also arrange to have a burial at home, although you will need to consult your local authority before doing so.

Cremation is an alternative to burial and can be performed at either the hospital or a local crematorium. However, not all crematoriums provide this service and they have no legal obligation to do so. There will not be any ashes for you to scatter after a cremation.

OVARIAN CYSTS

Ovarian cysts are fluid-filled sacs (pockets) that can grow inside or on the surface of your ovaries. They are usually removed using a surgical procedure called laparoscopy (keyhole surgery), but you may need open surgery.

Ovarian cysts are common in women of childbearing age. Most ovarian cysts are harmless and go away on their own. However, you may need surgery to remove a cyst if you have one that’s causing you pain or discomfort, or if it may be cancerous.

PMS

What is PMS?

Premenstrual syndrome or PMS is the name given to a collection of physical and emotional symptoms that can occur in the two weeks before you have your period. These symptoms usually get better once your period starts and often disappear by the end of your period.

Nearly all women have some premenstrual symptoms. Each woman’s symptoms are different but the most common symptoms include:

 mood swings
 feeling depressed, irritable or bad-tempered
 feeling upset, anxious or emotional
 tiredness or trouble sleeping
 headaches
 changes in appetite and food cravings
 feeling clumsy, possibly leading to increased accidents
 fluid retention and feeling bloated
 changes to skin or hair
 having sore or tender breasts.

Most women do not have all these symptoms, only certain ones. Sometimes the symptoms are the same each month and sometimes they are different. The symptoms form a pattern over time.

Between one and two in 20 (5–10%) women get PMS which is severe enough to prevent them from getting on with their daily lives. PMS usually improves after the menopause. A very small number of women get a more intense form of PMS, known as premenstrual dysphoric disorder (PMDD). This leaflet gives general information about PMS.

What is the cause of PMS?

The exact cause of PMS is not known. One or more factors may be involved including:

Changes in hormone levels

The levels of the female sex hormones estrogen and progesterone vary naturally during a woman’s menstrual cycle (the time from the first day of your period to the day before your next period starts). The symptoms of PMS are likely to be related to the cyclical fluctuation of these hormones. Women who use some methods of hormonal contraception are less affected by PMS.

Weight and exercise

Research has shown that the likelihood of PMS is increased in women who are obese – a body mass index (BMI) over 30 – and in women who do little exercise. BMI is the measurement of weight in relation to height. To calculate your own BMI follow this link: www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx. An excess of foods with a high salt content (crisps, convenience meals and fast food), alcohol (over 14 units a week) and caffeinated drinks have been shown to affect mood and energy levels.

Stress

Some women find that their PMS is worse when they are feeling stressed.

How do I know I have PMS?

There is no special test for PMS. If you are getting symptoms each month and are finding these difficult to cope with, you should see your GP. Your doctor or nurse will ask you to keep a diary or chart of your symptoms and when these occur, over at least two consecutive menstrual cycles. They will then review your diary with you to see if your symptoms fit the pattern of PMS. Seeing the same doctor or nurse will be helpful if your symptoms are distressing or vary a lot.

What are my treatment options?

There is a wide range of options to help you to manage your symptoms and allow you to get on with your daily life. Your doctor or nurse will talk with you about these.

Whatever option you choose, you will be advised to continue to keep a diary of your symptoms for at least two to three months, as this can help you to see if a particular treatment is working.

Changing your lifestyle

In the first instance you can take some positive steps to try and improve your symptoms by:

 taking more exercise
 eating a healthy balanced diet – decrease sugar, salt, caffeine and alcohol and increase fruit and vegetables. Eat wholefoods (wholemeal bread, wholegrain cereals, brown rice, wholewheat spaghetti, nuts and seeds). Eat lean meat, fish and chicken.
 finding ways to reduce stress
 talking with your partner or someone else you trust.

If your symptoms persist despite changing your lifestyle, you should be referred for more specialist gynaecological help.

Psychological support and therapy

Talking about your situation may help. Cognitive behavioural therapy (CBT) involves you being able to talk one-to-one with someone specifically trained in this area over several appointments. This can help you learn new ways of managing some of your symptoms to help reduce their impact on your daily life.

Drug treatment

There are a number of medicines for PMS, including:

Antidepressants

 There are many different types of antidepressants. Two types have been shown to help PMS symptoms in some women. These are SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors).
 Like all medicines, antidepressants can have side effects. Common side effects include nausea (feeling sick), insomnia (difficulty in sleeping) and low libido (not being interested in having sex).
 Antidepressants can be taken continuously, or every day for two weeks before your period and during your period.
 When you want to stop taking antidepressants it is important that you do so gradually. Your body can get used to these medicines, so if you stop taking them suddenly it can cause withdrawal symptoms such as headaches. Your doctor or specialist nurse will advise you.

Oral contraception – the combined pill

 Some women find using the combined pill helps with PMS. Newer types of contraceptive pills have been shown to improve PMS symptoms.

Patches and implants

 Using estrogen-only hormone patches or implants can improve your symptoms.
 Unless you have had a hysterectomy (removal of your uterus) these need to be used with a low dose of the hormone progestogen for a minimum of 10 days each month. This may be in the form of progestogen tablets or by using the progestogen-releasing intrauterine system (IUS) known as Mirena®. Mirena is also a very effective contraceptive.
 Estrogen hormone patches or implants do not work as contraceptives.
 It is important not to become pregnant while using patches or implants, so you will need to use contraception as well.

GnRH (gonadotrophin-releasing hormone) analogues

 GnRH analogues are injections (monthly or three-monthly) which should only be used by women with severe PMS and when all other treatments have failed.
 The drugs work by blocking the production of natural estrogen and progesterone and cause a temporary menopause, so you will not ovulate and you will not have any periods.
 You should only use GnRH analogues alone for up to six months. If they are used for longer than this you will be advised to take hormone replacement therapy (HRT) to reduce menopausal complications, such as osteoporosis (thinning of the bones).
 You should have a bone density scan each year to check for osteoporosis if you use these GnRH analogues for more than two years.

Progesterone or progestogen

 Taking natural progesterone or synthetic progestogen hormones does not improve PMS symptoms. It can take up to three months for you to feel the benefits of newer treatments, which is why it is important to complete your symptom diary before and during treatment.

Complementary therapy

There several alternative or complementary therapies for PMS. Many women find these helpful, although there is little evidence to show that they are effective. There is also little evidence that they do no harm.

 Ask your doctor for advice before using a complementary therapy.
 Inform your doctor if you are using any medicine or supplement. This is because some complementary therapies may react with other medicines. For example, St John’s Wort can make some hormonal methods of contraception (such as the pill) less effective. Some complementary therapies help only one or two symptoms. There is evidence that supplements of calcium and Vitamin D, magnesium or Agnus castus (a herb known as chasteberry) may be helpful. Evening primrose oil can reduce breast tenderness. Some women say they find vitamin B6 helpful.

Surgery

Removal of your ovaries, sometimes combined with removal of your uterus (hysterectomy) results in you having the menopause and can improve PMS symptoms.

 This is a major operation and your doctor will only suggest it if you have severe symptoms and all other treatments have failed.
 If you are younger than 50 years old you are likely to get menopause symptoms (hot flushes, drier skin) and you will be more at risk of osteoporosis after the operation. Taking HRT until the age of 50 can help menopause symptoms and protect your bones.
 If you are considering this option, your doctor may suggest you use GnRH analogues and HRT for three to six months. GnRH analogues have a similar effect on your hormones as having your ovaries removed and will give you an idea of how you will feel after the operation. By improving your symptoms, therefore, it will give you a chance to see if you will benefit from surgery. You will also be able to see if taking HRT after the operation will suit you.

Moving forward

PMS is common and many women are affected by its symptoms. Treatment, information and support are available to enable you to manage your symptoms and move forward with your life.

POLYCYSTIC OVARIES (PCOS)

What is polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is a condition which can affect a woman’s menstrual cycle, fertility, hormones and aspects of her appearance. It can also affect long-term health.

What are polycystic ovaries?

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

What are the symptoms of PCOS?

The symptoms of PCOS can include:

 irregular periods or no periods at all
 difficulty becoming pregnant (reduced fertility)
 having more facial or body hair than is usual for you (hirsutism)
 loss of hair on your head
 being overweight, rapid increase in weight, difficulty losing weight
 oily skin, acne
 depression and mood swings.

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

What causes PCOS?

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

The symptoms of PCOS are related to abnormal hormone levels. Hormones are chemical messengers which control body functions. Testosterone is a hormone which is produced by the ovaries. Women with PCOS have slightly higher than normal levels of testosterone and this is associated with many of the symptoms of the condition. Insulin is a hormone which regulates the level of glucose (a type of sugar) in the blood. If you have PCOS, your body may not respond to the hormone insulin (known as insulin resistance), so the level of glucose is higher. To prevent the glucose levels becoming higher, your body produces more insulin. High levels of insulin can lead to weight gain, irregular periods, infertility and higher levels of testosterone.

How is PCOS diagnosed?

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

A diagnosis is usually made when you have any two of the following:

 irregular, infrequent periods or no periods
 more facial or body hair than is usual for you and/or blood tests which show higher testosterone levels than normal an ultrasound scan which shows polycystic ovaries.

When a diagnosis is made, you should be referred to a gynaecologist (a doctor who specialises in caring for a woman’s reproductive system) or an endocrinologist (a doctor who specialises in the hormonal system).

How is PCOS treated?

There isn’t a cure for PCOS – your treatments aim to control symptoms of the condition. For some women their symptoms go away without any treatment but for most women, their symptoms get worse until they reach the menopause.

Self-help treatments

Your gynaecologist is likely to suggest that you make some lifestyle changes, such as eating a healthy, balanced diet and exercising regularly, to help control your symptoms, reduce insulin resistance and improve your fertility. Stress can make your symptoms worse so managing your stress levels and finding time to relax can also help control your symptoms.

If you have excess hair, you can control this with hair removing creams or by bleaching, shaving or waxing. Laser treatment and electrolysis can give longer-lasting results – see a qualified professional for these procedures.

Medicines

A number of medicines are available that can help treat the different symptoms of PCOS, which include the following.

 Over-the-counter treatments that contain benzoyl peroxide (eg PanOxyl) can help reduce acne. If over-the-counter treatments don’t help, speak to your doctor. He or she may prescribe antibiotic tablets or creams to treat your acne.
 Oral contraceptives (eg Dianette) can stop your ovaries from producing too much testosterone, so improve both acne and excess hair.
 Metformin is a medicine that increases the sensitivity of muscle cells to insulin (reduces insulin resistance). This means your body needs less insulin to control your blood sugar levels. Reduced insulin levels in the blood means your ovaries will produce less testosterone. As the testosterone levels drop, symptoms such as excess hair and irregular periods will improve and your ovaries will start to release eggs and your fertility will improve.
 Fertility medicines including clomiphene citrate and tamoxifen can stimulate your ovaries to release eggs. You can take these for up to a year. If clomiphene citrate makes you ovulate but you don’t become pregnant after six months, your doctor might suggest intrauterine insemination (this is when sperm is placed directly into your womb). If fertility medicines don’t help improve your fertility, your doctor may offer hormone therapy or surgical treatment. You can also consider assisted conception, such as IVF (in vitro fertilisation), egg donation or surrogacy. Always ask your doctor for advice and read the patient information leaflet that comes with your medicine.

Surgery

If medicines, such as clomiphene citrate, haven’t worked for you, your doctor may suggest surgery to control PCOS symptoms and improve your fertility, for example laparoscopic ovarian drilling. This is a type of keyhole procedure that destroys the tissue on your ovaries that produces testosterone. As levels of testosterone fall, your PCOS symptoms should improve and your ovaries should start to release eggs again.

POST-MENOPAUSAL BLEEDING

Any vaginal bleeding after the menopause needs investigation. Of those women who experience such bleeding approximately 5% of women will have some form of genital tract malignancy.

PMB is investigated initially with a pelvic ultrasound. If the lining (endometrium) of the womb is thin and can be seen clearly patients can be reassured and no further investigation is required. If the lining of the womb is thicker than expected then a hysteroscopy and a sample of endometrium should be taken for analysis.

Because of the risk of cancer, the early investigation of post-menopausal bleeding is important. At the gynaecology group we are able to guarantee an appointment with one of the Consultant Gynaecologists and a pelvic ultrasound and hysteroscopy being performed, if required, in less than 1 week from referral. This rapid service allows the earliest diagnosis and hopefully reassurance for patients.



Cancers

OVARIAN CANCER

Ovarian cancer is an abnormal and uncontrolled growth of cells that starts in your ovaries. It’s the fifth most common cancer in women in the UK.

In ovarian cancer, cells in your ovaries start to grow abnormally and out of control. The ovaries are two small organs that are part of the female reproductive system. They produce eggs every month in women of childbearing age, and the female hormones oestrogen and progesterone.

Ovarian cancer can sometimes spread more widely in your abdomen (tummy) or more rarely, to other organs through your bloodstream or lymphatic system. Your lymphatic system is made up of the tissues and organs in your body that produce and store cells that fight infection and disease. These include your bone marrow, spleen, thymus and lymph nodes. The channels that carry lymph are also part of this system. If ovarian cancer spreads to other parts of your body, it can form secondary tumours. The spread of cancer through your body is called metastasis.

Over 7,000 women in the UK are diagnosed with ovarian cancer each year, which makes it the fifth most common cancer in women. Worldwide, it’s the eighth most common cancer in women. Ovarian cancer mostly affects women over 50, but younger women can get it too.

Types of Ovarian Cancer

There are different types of ovarian cancer. The most common is epithelial ovarian cancer, which affects the lining of your ovaries. Nine out of 10 ovarian cancers are epithelial. There are several different types of epithelial ovarian cancer; the most common type is called ‘serous’.

Non-epithelial ovarian cancer is much less common. This type includes cancers that form from the cells in your ovary that make eggs. These usually affect younger women.

WOMB CANCER

Womb cancer (uterine cancer), is caused by an abnormal and uncontrolled growth of cells in your womb (uterus).

The Womb

Your womb is a pear-shaped, muscular organ in your lower abdomen (tummy). It’s part of the female reproductive system and is where your baby develops if you get pregnant. The lining of the womb is called the endometrium or endometrial layer.

Womb cancer is the fourth most common cancer in women in the UK – about 7,800 women are diagnosed each year. Most women who get womb cancer are over 50.

Womb cancer can sometimes invade surrounding tissue or spread through your bloodstream or lymphatic system to other parts of your body. Your lymphatic system is the tissues and organs that produce and store cells that fight infection and disease. A cancer that has spread is known as a metastasis.

Types of Womb Cancer

There are two main types of womb cancer.

 Endometrial cancer is the most common type and starts in the endometrium of your womb.
 Uterine sarcoma is less common and develops in the cells in the muscle wall of your womb.

CERVICAL CANCER

Cervical cancer develops if the cells of your cervix (the neck of your womb) become abnormal and grow out of control.

Around 3,400 women in the UK are diagnosed with cervical cancer every year. However, cervical cancer is one of the few preventable cancers.

Deaths from cervical cancer in the UK have fallen over the last 25 years. This reduction is mainly because of the NHS cervical screening programme which detects changes in the cells of your cervix at a pre-cancerous stage. If abnormal cells are caught early, cancer can be prevented.

Rapid Access service for women who have symptoms that are thought worrying for malignancy

An appointment can normally be offered within 24 hours for patients where urgent investigations are required to exclude cancer. This may be possible with examination but ultrasound or CT scanning may be required.

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