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Gynaecology

Menstrual Problems

Menstrual problems can affect women of all ages from adolescents to menopause. This is a term I have used to encompass many different symptoms that women may experience.

What are some menstrual problems women may have?

  • Heavy bleeding “Menorrhagia”- What women consider as normal periods defer greatly amongst individuals
    – Heavy bleeding can have a significant impact on a woman’s quality of life
    – Some of the causes of heavy bleeding include uterine fibroids, polyps, change in hormones, pre-cancer or cancer, bleeding disorders, medications (and the list goes on!)
  • No periods “Amenorrhoea”
    – Women or adolescents may have never had a period (primary amenorrhoea) or had periods then stopped having them (secondary amenorrhoea)
    – There are many causes for this including but not limited to pregnancy, hormone imbalances, life stressors, early menopause, chromosomal abnormalities
  • Bleeding in-between periods “Intermenstrual bleeding”
    – Some causes include changes of the cervix, uterine polyps, precancer or cancer
  • Erratic bleeding
    – Many of the causes of menorrhagia and intermenstrual bleeding can cause this
  • Painful periods “Dysmenorrhoea”
    – Most women experience some degree of discomfort with their periods due to the normal physiological changes that happen during this time
    – However sometimes the pain can affect ones quality of life, or be due to an underlying medical problem such as endometriosis

Do I need to see a Specialist?

Having these symptoms may mean that a woman has an underlying medical problem that needs gynaecology assessment and management. Particularly, some of these conditions can cause complications if not treated which can include infertility and cancer. It is important to see your GP to ascertain whether further assessment by a Gynaecologist is necessary.

When consulted, I will take a thorough history and do a physical examination. I may order some tests (if they haven’t already been done) such as blood tests and scans. Usually I will perform an ultrasound myself in the rooms. Sometimes I will take a biopsy of the uterus in the rooms or organise further examination in the operating theatre. We will then sit down and discuss the problem and talk about management of symptoms.

What kinds of management is there?

Management may include:

  • Medications e.g. hormones, the pill, anti-inflammatories, analgesia
  • Minor surgery e.g. hysteroscopy, dilatation and curettage, biopsy of the cervix, endometrial ablation (e.g. Novasure procedure), removal of polyps
  • Major surgery e.g. hysterectomy (removal of the uterus), removal of fibroids, key-hole surgery to further assess and treat likely problems such as endometriosis
  • Treatment of other medical problems e.g. bleeding disorders, thyroid disease
Pelvic Pain

Many women experience some form of pelvic pain. This can range from occurring sometimes, to continuous and chronic pain, and from mildly tender to debilitating, affecting one’s work and sometimes sex life. Some women have gone through multiple investigations and no cause has been found. It is important that women who experience pelvic pain be assessed correctly and be listened to by empathetic health professionals who are experienced in dealing with such conditions.

What can cause pelvic pain?

Some causes of pelvic pain may include:

  • Endometriosis
  • Adenomyosis
  • Adhesions
  • Pelvic Inflammatory Disease
  • Ovarian cysts

When assessing someone with pelvic pain, I will take a thorough history and do a physical examination. Sometimes I will do an ultrasound in my rooms or refer you to get some special investigations.

It is important to exclude some conditions and not delay diagnosis as this could worsen symptoms or lead to complications such as infertility. It is also important that we look at problems in a holistic manner and ensure that women who suffer from this condition can aim to get back to, or continue to function well in their daily activities.

What are some treatments for pelvic pain?

Often a combination of treatments are necessary to treat pelvic pain. These may include:

  • Medication: e.g. anti-inflammatory medication, the pill, hormones
  • Surgery:
    – Laparoscopy to see what the cause could be, and at the same time to treat pathology if found (e.g. laparoscopy plus removal of endometriosis)
    – Hysterectomy
  • Referral to other health professionals e.g. Pain Specialists, Urologists, Gastroenterologists
Ovarian Cysts

What are ovarian cysts?

Ovarian cysts are fluid-filled sacs that may contain fluid, blood or other tissue. Cysts on the ovary are common and can occur normally and usually resolve on their own, for example, as part of a woman’s menstrual cycle. Sometimes cysts can become very big, burst, be infected, twist or be cancerous. If some of these events occur, emergency surgery may be required.

What are the symptoms?

Ovarian cysts often have no symptoms and are found by chance on an ultrasound or other investigation. There are certain features we look at to give us an idea of whether a cyst looks physiological and benign (that is, non-cancerous) and those that look suspicious for cancer (pathological). Sometimes they can cause pain, pressure or bloating.

How are ovarian cysts treated?

Depending on the risks, what the cyst looks like, symptoms, history, and family history, I may suggest the following treatments:

1. No treatment necessary: for instance, if the cyst is small, and looks like a simple cyst that occurs normally in a menstrual cycle
2. Surveillance ultrasounds: if the cyst doesn’t look suspicious but we need to make sure it doesn’t grow or change
3. Surgery: e.g. for large cysts, suspicious looking cysts, if there is pain or risk of cancer

Removal of cysts via surgery:

A cystectomy is a procedure where the ovarian cyst is removed and I usually do this via minimally- invasive surgery (laparoscopy) to reduce the need for an open cut, reduce scarring and pain, and to minimise recovery time. During a laparoscopic cystectomy, a small cut is made in the naval where a long, thin camera is placed to get a view of the pelvis whilst other instruments are used to remove the cyst. This procedure is done under general anaesthesia and is often either a day-procedure or overnight stay.

Occasionally an open surgery (bigger incision) is required for complicated cysts and sometimes the cyst and the ovary will be removed at the same time (e.g. in postmenopausal women).

Surgery is better to be done as an elective procedure with good preparation rather than an emergency procedure where complications can occur.

If you have been diagnosed with an ovarian cyst and referred to us, I will take a thorough history from yourself and then examine you. I may perform an ultrasound in my rooms. Each woman is individual and therefore a specific plan will be devised, in conjunction with yourself to manage the cyst and your symptoms.

Abnormal Pap Smears

What are Pap Smears?

Pap smears and Thin Prep are screening tools used to determine a woman’s risk of having cervical cancer. Because it is only a screening tool, it cannot diagnose whether a patient has cancer or not, rather it gives a risk of cancer. The pap smear looks for changes to the cells of the cervix, that if left untreated, may go onto become cancerous. Most of these changes, thankfully, do not go onto become cancer and are cleared naturally from our bodies. However, if any abnormal changes are detected, it is very important to be referred to a Specialist Gynaecologist so that the correct treatment or surveillance can be determined.

In Australia, due to an excellent screening program and follow-up, our rates of cervical cancer are very low. Early detection of cancer and pre-cancerous lesions also means less intervention and improved survival rates. The HPV vaccination which protects women against the Human Papillomavirus (HPV) which causes cervical cancer and genital warts, has also worked to reduce these rates. HPV is present in 99.7 percent of cervical cancers, however not all HPV infections lead to cancer. In most cases, the virus is cleared naturally with time. However, sometimes it doesn’t clear and this can increase the risk of developing cervical cancer.

Pap test results

You may be referred to a Specialist after your pap test due to an abnormal result, examination or because of some of the symptoms you might be experiencing (such as bleeding). If consulted, I will review your results, take a thorough history and most likely perform a colposcopy examination.

What is a colposcopy?

Performing and interpreting colposcopy requires specialised training. During this examination, I use a colposcope (which is a microscope on a stand) to better view the cervix through a speculum (the same device used to take a pap smear). I can then determine the extent of any abnormality and may suggest that a biopsy be taken. This procedure usually takes around 5-10 minutes and doesn’t usually cause any pain.

What treatment may be required?

Treatment options depend on what the results are of the pap smear, colposcopy (and possibly biopsy), symptoms, risk factors and age. Every woman is individual and therefore a specific treatment plan will be devised in conjunction with best practice and after discussion with the patient. Treatments may include:

  • Repeating the pap smear in e.g. one year
  • Large loop excision of the transformation zone (LLETZ): which is basically a bigger biopsy of the effected area which aims usually required for this.
  • Cone biopsy: a cone-shaped biopsy is taken under general anaesthetic when the abnormal cells are higher in the cervical canal.
Adolescent Gynaecology

What gynaecological problems may adolescents face?

Adolescents, teenagers and young adult women may face some gynaecological problems that are unique to this group because of the possible different causes or treatment options for this group. These problems may include:

  • Abnormal menstrual bleeding (e.g. heavy bleeding, absent menstruation, early or delayed menstruation)
  • Medical conditions that may affect menstruation (e.g. bleeding disorders, being on blood- thinning medications, epilepsy)
  • Pelvic pain, endometriosis
  • Ovarian cysts
  • Problems with growth and puberty
  • Concerns regarding contraception
  • Pelvic infections
  • Endocrine problems e.g. polycystic ovarian syndrome, acne, excess hair
  • Girls with special-needs (e.g. disabilities)

Due to age, continued growth and psychosocial aspects that are specific to this group, I ensure that specialist care is offered in a sensitive, appropriate and caring manner.

Contraception

Birth control or contraception is a means of preventing pregnancy. There are many different methods of contraception such as natural family planning, medications, intra-uterine devices (IUDs), implantations and surgical methods.

Which method is right for me?

Every woman is unique and contraception needs to be individualised depending on your age, health, sexual activity and plans for future pregnancies. Therefore, it is important to have a good discussion with your health practitioner and be well-informed with regards to all the different choices.

Why see a Specialist?

Your GP or health practitioner can usually advise you on many of the contraceptive methods available and may have managed your contraception already. You may be referred to me due to special circumstances, Specialist advice, or to perform a procedure.

What are some methods of contraception we might discuss?

For a comprehensive and accurate description of the different contraceptive methods, advantages and disadvantages, visit The Better Health Chanel at:
https://www.betterhealth.vic.gov.au/health/healthyliving?f=6C6F6B1D982347A48254ACCF2866AA65~542AAC231DB94A019ECED027D6F5BE40

Some of the methods we may particularly discuss include:

  • Contraceptive pill:
    Contraceptive pills contain hormones (estrogen and progesterone or progesterone only) and prevent ovulation (egg release) as well as changes in the uterus and cervix to prevent implantation. There are many different types of pills with different combinations/types of hormones. Some pills will suit some women and some will not, and there are side-effects of hormonal pills that also need to be considered. You may have special circumstances or needs that would benefit from a different type of pill or dose for e.g. you may be on some medications, or have a medical condition. Some pills also have added benefits such as treating excessive hair growth or acne.
  • Implanon:
    This implantable hormone device contains etonogestrel, a progesterone-like hormone that prevents ovulation and also acts at the uterus and cervix to prevent sperm penetration and implantation of the embryo. It is a small rod the size of a matchstick which is inserted under local anaesthetic under the skin in the inner arm. Advantages includes a nearly 100% effectiveness, lasting for 3 years, safety with breastfeeding and low cost. I am able to insert this in my rooms during your appointment.
  • Intra-uterine devices:
    In Australia there are two types of intra-uterine devices (IUDs) – the Mirena (hormonal) and copper IUD – that may be inserted into the uterus to prevent pregnancy. Both types are very effective contraceptive methods and can be fitted in my rooms without the need for general anaesthetic. Benefits include long-lasting (5 or 10 years), easy to remove if needed, return to fertility immediate post removal. Both of these type effects that should be considered prior to insertion.
  • Surgical methods:
    Female sterilisation is a permanent method of contraception. This can be done via hysteroscopy or laparoscopy. Main methods that I will discuss with you include filschie clips, Essure and tubal ligation. As these are permanent methods, you must be sure that you do not want any future children, even if circumstances or relationships change, reversal of these procedures are not always recovery time.