|
Ask The Expert |
|
|
|
|
| Question from SunLuvr: |
| I have been recently diagnosis with fibroids. I have two tumors 4cm in size. The only symptom I have is bladder pressure. I have been taking soy products for menopausal symptoms for over a year. I am 47, my question is would the plant estrogen from the soy stimulate the fibroids and would not taking the soy products have any effects on my fibroids. |
| Answer from Dr. Toub: |
| If you had a tubal ligation, you should in theory not be able to conceive. Also, it would be potentially dangerous to carry a pregnancy after an endometrial ablation, since there is a risk of the placenta growing into the uterus and necessitating an emergency hysterectomy as a lifesaving measure. Ablation does not remove the possibility of pregnancy, and while tubal ligation failures can happen 8 or more years after the fact, hopefully this will continue to provide reliable protection against pregnancy. Conception after an ablation is not advisable. |
| Question from Regina: |
| I recently underwent a total vaginal hysterectomy. While in surgery my bladder was severely damaged by a four-inch
laceration. My doctor tells me that the walls of the bladder are paper-thin and this is something that could not be avoided. Please give me some information on the anatomy of the bladder and possible side effects of this incident so that I can begin to come to grips with what I face ahead. |
| Answer from Dr. Toub: |
| Incidental injuries to the bladder can happen even in the best of hands. When recognized at the time of surgery and appropriately managed, they generally are of no long-term consequence. The bladder is a very forgiving organ and heals really well. Problems are much more often seen when the injury is not recognized at surgery and the bladder is left without an indwelling catheter for many days. The bladder heals usually within a week. In fact, some urologists claim that even if the bladder isn't repaired, it will still heal just fine if the bladder is drained for at least a week with an indwelling catheter. Your doctor really should be the one to address this with you. As far as the anatomy of the bladder, I would refer you to any of a number of good anatomy books, but again, your doctor can explain this to you as well. |
| Question from Sheryl: |
| I'm 35; I was diagnosed with endometriosis at age 20. My doctor and I have communicated very closely and I know
all the options available to me. I am having a hysterectomy in March (Removal of Uterus and Ovaries). However, I am still concerned about how the procedure will affect sexual desire and my ability to have an orgasm. I have read that without the uterus there will no longer be "contractions" during and after orgasm? Doesn't this affect the intensity of orgasm? Vaginal dryness is another concern.Will hormones therapy i.e., Premarin help with this condition? Or will I always need to keep a supply of K-Y in the medicine cabinet? I have done research and read up on these topics but I want to gather as much information as I can and would like to hear your opinion. |
| Answer from Dr. Toub: |
| While not totally understood, it appears that except for a small subgroup of women, hysterectomy does not significantly diminish sexual function. As far as lubrication, that would depend on whether or not the ovaries are removed at the time of hysterectomy, in which case estrogen replacement therapy often is quite sufficient for lubrication. KY or other vaginal lubrication products may be helpful in appropriate patients. |
| Question from Beth: |
| My 70-year-old mother has been diagnosed with rectocele. The rectocele is now causing severe discomfort and ongoing UTI's. Her doctor has recommended surgery to repair the weakness and a hysterectomy. At my mother's age and being at postmenopausal, is a hysterectomy necessary? |
| Answer from Dr. Toub: |
| No-unless there is a coexistent indication for hysterectomy in and of itself, there is no evidence that hysterectomy is necessary just to repair rectal and/or bladder prolapse. If there were significant uterine prolapse it would be advisable to do a hysterectomy, but if the uterus is not causing problems most authorities would suggest leaving it be. Of course, everyone has different opinions on this, and I would defer to your mother's physician all things being equal, since much of this is determined by individual experience as well. |
| Question from PrimAndProper: |
| It has been recommended that I have a hysterectomy. I am 42 yrs old, and have not begun menopause. My doctor has asked me to consider having my ovaries removed, which would throw me into menopause. In the past, I have not had much success with birth control pills. The side effects are terrible; joint pain, water weight gain, headaches etc. I'm concerned that I will have the same response to hormone therapy after the surgery. What are the risks of a hysterectomy? Is it a routine procedure? Please advise me on how all of this will work together. I feel the hysterectomy is optional, but would eliminate the heavy bleeding, skin problems, mood swings and pain I now experience.Please give me as much information as possible to make an informed decision. |
| Answer from Dr. Toub: |
| In all honesty, it is your gynecologist's duty to provide enough information to make an informed decision about surgery. I would suggest you speak at greater length with him or her about this subject, since it would be inappropriate for me to serve as your surrogate gynecologist in this matter. |
| Question from Barbara: |
| Could you please tell me what could be done about a prolapsed uterus? How long is the recovery if surgery is done? |
| Answer from Dr. Toub: |
| Depending on the degree of prolapse and symptoms, options range from hysterectomy to nothing. A pessary can also be placed to support the uterus, although depending on the pessary type intercourse may not be possible. Recovery times depend on many factors, including which operation is performed, and I would refer you to your doctor for further discussion. |
| Question from Debbie: |
| Four years ago I underwent a hysterectomy and right oophorectomy due to PCOS and adenocarcinoma. I was told that leaving the remaining ovary and laser treating it will prevent early menopause. Is this procedure commonly done in such cases as this? How long does the remaining ovary usually continue to work/delay the onset of menopause? I am 34 years old now. I was wondering if the ovarian drilling that was done at the time of the hysterectomy would also help to delay the onset of menopause? Should I be tested regularly for hormonal levels and do I need a pap smear any longer? My gynecologist that was seeing me has since retired. Any info you can shed on this will be appreciated |
| Answer from Dr. Toub: |
| Ovarian drilling is not an uncommon procedure for PCO, although I'm not aware that its main role is delaying menopause. Rather, ovarian drilling is intended to normalize ovarian function and relieve some of the symptoms of PCO. I would not suggest regular hormone testing, since such tests are not cost-effective. You will need a Pap smear at least annually or as recommended by your doctor. (You will need to find a new gynecologist, perhaps one who took over your former doctor's practice). |
| Question from Jane: |
| I have been diagnosed with a "solid mass" about 1.9cm x 2.4 cm on one ovary. Had a sonogram, CAT scan
and a second sonogram after a period showed the size reduced, consistency changed and two cysts that had formed.
I am scheduled for laparoscopy in three weeks and will no doubt have that ovary removed. I am really debating,
at age 42, whether or not to: a) have both ovaries removed b) have a full hysterectomy c) just have the one ovary removed I am seeking some objective, scientific-based opinions on this, as everyone I know has their own subjective opinion, and I don't need that! I don't plan on children, and frankly, am concerned that removing one ovary will just mean that the problem will migrate to the other ovary. Can you offer some different looks at this, please? |
| Answer from Dr. Toub: |
| Depending on what is found at laparoscopy, it may be reasonable to remove the cysts and preserve the ovary, or remove the involved ovary and preserve the other. If there is a precancerous ("borderline") tumor or frank ovarian cancer, then a hysterectomy, removal of both ovaries with appropriate surgical staging would be the standard treatment, and this is something I'm sure your doctor has discussed with you. While some ovarian tumors (benign and malignant) can occur bilaterally, if only one ovary is currently involved in a benign process there is no major reason to be concerned that the problem will occur on the other side. Objectively, the risk of ovarian cancer over an average woman's lifetime is about 1 in 70, or 1.4%. Whether to remove both ovaries is a personal decision-there is no right or wrong answer-but one must also take into account family history, ovarian cancer risk, etc. If both ovaries are removed, hormone replacement therapy would be an option, but if at least one ovary were preserved you might not pass through the menopause for many years. This is something you should discuss with your doctor, who can advise you on an individualized basis. |
| Question from Joe: |
| After having a total hysterectomy in my early 20's, I am now mid 40's. I am currently taking Estratest. Am also
experiencing a severe lack of libido. Are there any medications out there to help stimulate the libido for women? |
| Answer from Dr. Toub: |
| There are combination estrogen/testosterone formulations that in theory can help with libido in selected women. Androgens like testosterone do play a role in libido. However, changes in libido may also be a sign of other problems, and it would be advisable to speak with your doctor who can help you decide if counseling rather than additional hormonal medication might be the more appropriate plan of action. |
| Question from Krystil: |
| Due to enlarged fibroid tumors and an enlarged uterus (10 week pregnancy size) causing pelvic pain my doctor has recommended an abdominal hysterectomy. She said I can't have it done vaginally because of the uterus size. Isn't there a way to shrink the uterus and fibroids before surgery so this procedure can be done vaginally? |
| Answer from Dr. Toub: |
| Not to disagree with your doctor (since there is a wide range of opinions on this subject), but in many cases a
10-week sized uterus can be approached vaginally without pretreatment. In experienced hands, even a 20-week uterus
can be removed, but not everyone has the requisite training for this. If pretreatment were desired (and this may
or may not be necessary), a 2-3 month treatment with GnRH agonist medications can shrink the fibroids by about
50% in many cases. The downside is that you would have the symptoms of menopause for 2-3 months. Another issue
in this case, however, is whether or not a hysterectomy is really necessary. A 10-week uterus is not that enlarged,
and unless there are significant symptoms such as pain and/or bleeding, a hysterectomy is not indicated for size
alone. Also, there are many alternatives to hysterectomy, particularly if you are not planning to have additional
children. So you may want to get a second opinion. Again, there are going to be differences of opinion in medicine,
but in my experience there are many ways to treat fibroids other than hysterectomy. If you are not having symptoms there may be no reason to intervene at all. |
| Question from Margaret: |
| I have been asked by my OBGYN to acquiesce to taking Depo injections for three months to shrink uterus/fibroid prior to surgery. I have been unsuccessful in researching the Depo. All I find is Depo-Provera and that is not correct.Would appreciate any information regarding Depo- GNRH/Agonist. |
| Answer from Dr. Toub: |
| Progesterone can, in some cases, cause temporary shrinkage of fibroids, and it is a lot cheaper than GnRH agonists (and lacks the menopausal side effects as well). However, the GnRH agonists tend to be more effective in my experience and are more predictable. You should not feel that you have to acquiesce to anything, however, and your doctor should be able to provide you with info regarding GnRH agonists. The main downside is the menopausal symptoms (and bone mineral loss if taken for over 6 months, which fortunately is not necessary to shrink fibroids). |
| Question from Joanne: |
| I am having some post-coital staining four months after complete hysterectomy.If this is "granulation" could you please tell me what it is and if I can let it go for a couple months till my next check-up? |
| Answer from Dr. Toub: |
| I'm not sure you should let it go, however. By four months, the vaginal apex should be well healed (granulation is the process by which such wounds heal). Your best course is to have this checked out just to be on the safe side. |
| Question from Evie: |
| I am 44 with history of PCOS and currently am perimenopausal. I also have been diagnosed with prolapsed rectum and fallen bladder although I have no incontinence. I am having untreatable headaches daily---could this be due to the Estripropipate and Provera? I have a family practitioner that thinks not and through him has made an appointment for a hysterectomy, rectocele and cystocele with a general surgeon (he is board certified). I am very nervous about this as for the most part with the exception of the plumbing I have been in excellent health. The headaches are a concern, as I have never had them before. I thought people made them up to get out of doing things. The only thing different is the hormones that I am taking. My fear is that I will go back to being forgetful and anxious if I have to stop them and that I lose interest in sex due to surgery. I do enjoy it now. Any suggestions?? |
| Answer from Dr. Toub: |
| The hormones can be given generally the day after surgery so I would not be too concerned about having to discontinue them for a long period of time. Whether or not a hysterectomy is necessary is debatable, and would depend on any symptoms and physical findings. In the same vein, a rectocele and cystocele do not require surgery unless they cause symptoms, so I am assuming that you have symptoms significant enough to merit surgical intervention. Some cystocele (bladder hernia) repairs can cause incontinence, depending on the type of cystocele (anterior vs. posterior) so you should have a discussion with your doctor preoperatively about the risks of incontinence and other associated risks. |
| Question from Hazel: |
| I had my tubes "cut and burnt" in 1996, and then I got divorced. I have 2 kids from my previous marriage and I'm desperate to have a baby with my new husband. A few months ago there was an advertisement for a documentary on TV regarding the reversal of these types of procedures and I know there must be some technology out there that could help me. I visited my doctor who did the surgery and he told me that it couldn't be reversed. Is this true? |
| Answer from Dr. Toub: |
| Generally, sterilization is intended to be permanent. Depending on the condition of the tubes after tubal ligation,
it may be possible to reconnect them, but only after a thorough infertility evaluation of you and your partner.
In addition, such surgery entails risk, may not work in about 40% of cases depending on the condition of the tubal
segments, and increases one's risk of tubal pregnancy (which is life-threatening). To make it even more problematic,
this surgery is often not covered by third party payors. So while in many cases tubal ligation can be reversed,
there are many things you need to consider beforehand. I would also recommend that someone perform such surgery,
if it is undertaken, with experience in this operation and who performs numerous tubal reversals annually. |
| Question from Lisa: |
| I was diagnosed last November with severe endometriosis. My doctor said it is so severe that it is weighing my ovaries down and that it cannot be removed due to the locations of the disease and for fear of internal bleeding. She informed me that I had two options; one was to start a new treatment called Lupron or to have a complete hysterectomy. She was very insistent to start me on the Lupron injections; I agreed to try it. Even though this treatment is not a cure, and is only supposed to shrink the disease, I am seriously considering having the complete hysterectomy, because I would rather live with the hot flashes that go along with menopause than to live with this pain. Even though I am on the Lupron injections, if I decided to go ahead and have the hysterectomy, do I have to wait a certain period of time before doing so? |
| Answer from Dr. Toub: |
| No-to the best of my knowledge there is no need to wait to have surgery while on Lupron. However, you should take enough time to weight all the potential risks of and alternatives to the surgery. |
| Question from Korene: |
| I had a hysterectomy 3 months ago with the birth of my daughter, because I was hemorrhaging. I now feel a constant
sensation inside my vagina, it is hard to describe, and it feels sort of like a pressure, like there is something inside of my vagina. Could this be due to vaginal prolapse? |
| Answer from Dr. Toub: |
| It's hard to say-the best way to get at the bottom of this is to have an examination by your doctor. |
| Question from Marlene: |
| Before my hysterectomy I would douche maybe every other month. Now after surgery (October, 1999) I feel the need to douche. Can I douche? |
| Answer from Dr. Toub: |
| While there are differences of opinion on this, it is probably not necessary from a medical standpoint to douche. It may alter the pH of the vagina and lead to yeast infections, although some recent evidence suggests otherwise. You should also touch base with your own doctor on this issue. |
| Question from Muckbuster: |
| One week ago my doctor put me on Estratest (with 1.25 milligrams of Premarin). I am 46 years old and 6 months ago had a complete abdominal hysterectomy. I have not truly felt myself since and I went to him complaining of foggy memory, and lack of energy. My question is: How long before I should notice an improvement in my symptoms? If I don't notice any improvement, are there other hormones I can try? |
| Answer from Dr. Toub: |
| It's hard to say how long it will take to notice a change, but I would think that if you do not notice an improvement in a reasonable period of time your doctor should consider other reasons for your symptoms besides a lack of estrogen. Personally, I'm not sure that estrogen replacement would be the first thing to try in this situation, as your lack of energy could be due to any of a number of reasons including anemia. Also, unless you are postmenopausal, there would be no reason to start estrogen at this time. The memory problems also may not be due to a hormonal deficiency, and should be discussed with your doctor and possibly another specialist such as a neurologist to be on the safe side. |
| Question from Kate: |
| I have been diagnosed as having possible Adenomyosis, but the doctor says that he cannot know for sure until he does a complete hysterectomy. Isn't there any other recourse, I do not want to feel pressured into having an unnecessary operation. Last week I under went exploratory, he believed that I have fibroid tumors but that proved not to be the case. I would like to be able to go and discuss other options with my doctor besides a hysterectomy. My next appointment is with him on Friday (February 18th). |
| Answer from Dr. Toub: |
| Adenomyosis cannot be definitively diagnosed in the absence of a hysterectomy, although MRI and sometimes ultrasound can be helpful in supporting the diagnosis. As most uteri will contain at least a small focus of adenomyosis if the pathologist looks hard enough, it is a matter of distinguishing between truly symptomatic adenomyosis and incidental cases that do not require treatment. I would suggest you discuss an MRI with your doctor if there is an uncertainty about the diagnosis as it would be unfortunate to have surgery only to find that the diagnosis of adenomyosis was not supported when all is said and done. Also, unless you are having symptoms that are worthy of surgery, it may not be necessary to have the operation. In some cases, a trial of GnRH agonist medications might be helpful to see if they relieve the symptoms, although they cannot be used long term. At least a trial of GnRH agonists would also help support or refute the diagnosis of adenomyosis. A second opinion would also be helpful. |
| Question from BJ: |
| How would I recognize a gynecological prolapse of the vaginal wall or uterus? |
| Answer from Dr. Toub: |
| Unless it is severe, it is only visible on pelvic examination. A severe case of uterine or vaginal prolapse, in which part of the uterus or vagina protrudes past the vaginal opening, would be obvious to you. Lesser degrees of prolapse may cause pressure symptoms, but would not likely be obvious except on exam. |
| Question from Bertrac: |
| I am scheduled for a hysterectomy next week. I experience heavy bleeds and pain. Is embolization or balloon procedure an option? |
| Answer from Dr. Toub: |
| Ideally, your doctor should discuss all risks, benefits and alternatives to the operation with you ahead of time. Whether or not embolization is appropriate depends on many factors that would be best discussed with your gynecologist. Embolization is an option for many women, but remains somewhat less time-tested than other alternatives to hysterectomy. Again, your doctor, or a physician rendering a second opinion, would be able to discuss this issue with you at length. |
| Question from Connie: |
| My question is, in your experience does endometriosis spread rapidly or slowly? Should a person have it taken care of before it gets worse or can it be left alone? |
| Answer from Dr. Toub: |
| It used to be thought that endometriosis is a progressive disease in all cases. It now appears that endometriosis often gets no worse than it appears at the time of initial diagnosis, although this will vary depending on the patient and physician. Whether or not to intervene depends on many factors, such as symptoms, stage of the disease and desire for fertility. Your best option is to speak with your gynecologist and see if treatment is indicated at this time. |
| Question from Dawn: |
| I have had laser surgery for class 3 cancer cells, heavy bleeding and large clots. Also, the doctor has tried birth control pills and D&C's. My doctor recently did a pap smear that has turned out to be bad. I still have to see the doctor before I know the results. Should I seek a second opinion? |
| Answer from Dr. Toub: |
| I'm not sure what the indication for the second opinion is at this point, as no definitive diagnosis or treatment plan is being presented. Of course, it never hurts to get a second opinion, but you may want to make sure that you have as much information as possible before obtaining one. |
| Question from Doris: |
| Can I conceive after having my uterus taken? |
| Answer from Dr. Toub: |
| No, after a hysterectomy, fertility is no longer possible. Your doctor should inform you of this fact in any discussion regarding the risks of hysterectomy. |
| Question from Janine and Sanaya: |
| What are the advantages and disadvantages of endometrial ablation? After having endometrial ablation is it necessary to use contraception? |
| Answer from Dr. Toub: |
| In brief, endometrial ablation is an alternative to hysterectomy for women with intractable, significant abnormal
uterine bleeding that otherwise would require a hysterectomy. The advantages are many, and include a shorter length
of stay (it is an outpatient procedure as opposed to a hysterectomy which requires at least an overnight stay in
the hospital), no incision, and potentially less risk (although there are still some significant risks associated
with ablation, though they are fortunately uncommon in skilled hands). Disadvantages-there is a failure rate (so
that some women may ultimately require either a repeat procedure or a hysterectomy), not all women will have complete
cessation of menses (although most will benefit from the procedure in terms of having a reduction in menstrual bleeding), and pregnancy is not advisable. Reliable contraception must be used after an ablation-like hysterectomy; ablation is not designed for women who desire fertility. In many cases, tubal ligation is performed at the same time as the ablation. The concern is that after an ablation, if pregnancy occurs the placenta could grow into the uterine wall, which is a very dangerous condition and usually requires hysterectomy as a life-saving measure. Also, ablation should not be performed in women with fibroids unless the fibroids are removed at the same time, since this lowers the success rate of the procedure. Ablation should only be performed by competent, experienced gynecologists, and there should be confirmation beforehand that the uterine lining does not contain any premalignant changes. Your gynecologist should be able to provide you with more individualized information. |
| Question from Nancy: |
| I've read about alternatives like Depo Provera, Lupron, Myomectomy and Embolization. Is there any regime that I can go on that would manage growth of my fibroids until I hit menopause, at which timeI understand the fibroids would shrink on their own? |
| Answer from Dr. Toub: |
| Symptomatic fibroids are not generally amenable to medical treatment except on a temporary basis. However, if a woman is near to the average age of menopause (late 40's to early 50's), a short course of GnRH agonists may tide that woman over until natural menopause occurs, in which case the fibroids would remain in an inactive state and shrink. Depending on your age and situation, this may or may not be appropriate for you. Your doctor can provide you with additional details. |
| Question from Nikki: |
| After having a laparoscopy for endometriosis my doctor placed me on birth control pills. I have been on two kinds of birth control one doesn't take care of the pain; the other cause my legs to swell and have break through bleeding. Over time, I am hoping the birth control pills will work. What are my options? What are the advantages and disadvantages of these options. |
| Answer from Dr. Toub: |
| You should speak with your doctor about other modes of hormonal intervention, such as progesterone or GnRH agonists, as well as different pain regimens. The birth control pill, frankly, is not the best treatment for endometriosis and is not effective in improving fertility rates either. It also depends on what was found and done at the time of your laparoscopy. |
| Question from Kris: |
| My pap smear came back abnormal and I want to make sure I get the best care available. Advil does not help the pain I am having either. What are the possible causes of the abnormal pap and the pain? |
| Answer from Dr. Toub: |
| Cervical dysplasia (abnormal cells on the cervix) does not cause abdominal or pelvic pain. The evaluation of the Pap depends on the actual Pap smear results-some abnormalities require colposcopy and biopsy; others can be managed with a repeat smear. You should speak with your doctor about this, as well as the pain, since both problems need attention. |
| Question from Linda: |
| My ovaries were reconstructed during a laparotomy. Now I have fibroids and a cystic mass on my uterus. Would I be healthier without these organs; I won't be able to take hormone replacement for six months? What actually warrants a bilateral salpingo-oophorectomy? |
| Answer from Dr. Toub: |
| These are all issues that are more appropriately dealt with by your gynecologist. Whether or not surgery is indicated depends on many factors in your history, along with recent tests such as an ultrasound. I'm not sure why you would not be able to take HRT for six months post-op, nor is it clear if removal of the ovaries would be required. Again, this is a question that requires a thorough knowledge of your personal medical history and is not appropriate for an internet-based forum. Your doctor can provide you with a specific diagnosis and treatment plan. |
| DISCLAIMER: The Expert Section is not the place to include lengthy medical histories Any long questions or urgent matters should be placed on the Women's Health Forum. The above represents material for educational and discussion purposes only. The material provided should NOT be used for diagnosing or treating any health problem or condition. It is NOT a substitute for consultation with and advice from qualified healthcare providers. If you have or suspect you have a health problem, consult a qualified healthcare provider. The author and any other party involved in the preparation or dissemination of the material presented are not responsible for any errors or omissions in the material provided above, or any results obtained from the use of such material. |
