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Ask The Expert |
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This month's topics |
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| Endometriosis | ||
| Question Can Endometriosis return after a complete Hysterectomy? Ovaries, Tubes and Uterus were removed. Does starting HRT too soon after surgery be the cause? If it does return, What is the best way to treat it? |
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| Answer Endometriosis can recur after removal of the ovaries, often due to the conversion of the hormone androstenedione to estrone by adipose tissue (fat cells). Up to 15% of women will have a recurrence of endometriosis after removal of the ovaries, regardless of whether or not estrogen replacement is prescribed (based on an anecdotal study by David Redwine). There is no consistent evidence in the literature that demonstrates an advantage to delaying estrogen replacement after removal of the ovaries in patients with endometriosis. In selected women, there may be an advantage to delaying the initiation of estrogen replacement therapy, but there may not be any advantage as well, so such decisions need to be individualized. As far as how to manage recurrent endometriosis, that also will vary from physician to physician. Many physicians would probably start with some form of hormonal intervention, but even more important is to establish the diagnosis of endometriosis, since postoperative adhesions can also result in pelvic pain and this is not amenable to hormonal treatment. |
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| Question Can Provera jump-start one’s period after taking Lupron to treat stage 4 endometriosis, adhesions, and cysts? |
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| Answer The reason why GnRH agonists like Lupron prevent menstrual periods is that they turn off the production of estrogen and progesterone by the ovary. Until estrogen production normalizes, there will be no uterine lining to shed if a woman were to take progesterone (Provera and others) for a few days. Once estrogen has returned to normal levels and the uterine lining has proliferated, then a short course of progesterone could cause an early menses, but there is generally no medical need for this in this setting. Your gynecologist can advise you further. |
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| Fibroids Treatments | ||
| Question I have fibroids that cause me to bleed half the month (14 days). What options is available for treatment? I want to avoid a hysterectomy if possible. |
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| Answer The available options depend on many factors, including your desire for future fertility. Myomectomy is an operation in which fibroids are removed, preserving the uterus. This may be accomplished through a laparotomy (regular, large) incision, laparoscopy (in some cases) and even hysteroscopy on occasion. Myomectomy is appropriate for women whether or not they desire future fertility, although a Cesarean section is often recommended to deliver future pregnancies and avoid the possibility of uterine rupture during or before labor. Other options include myolysis, which is a laparoscopic procedure that destroys the blood supply of the fibroid, cryomyolysis, which is a variant of myolysis that freezes the fibroid, and uterine artery embolization. None of these procedures have been demonstrated to be conclusively safe with regard to future pregnancies, and in general women who have myolysis or cryomyolysis should use reliable contraception (preferably female or male sterilization) and not get pregnant afterwards. While there have been reports of successful pregnancies after uterine artery embolization, (a radiologic, non-surgical procedure in which the blood supply to the uterus is blocked and the fibroids gradually shrink), this procedure has not been around long enough to fully conclude that it is appropriate in women who desire future fertility. Your gynecologist should be able to counsel you regarding which options are appropriate for you. Surgical experience and preference is also a critical factor, as not every gynecologist will recommend alternatives to women who have completed childbearing, nor is every gynecologist appropriately trained in some of these methods. |
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| Question I know there is all kinds of symptoms with fibroid tumors. I have them and I have all kinds of problems from them. I bleed heavily and have even ruined clothes. I know there is medication I can take but I prefer not to because they depress me. Do you have any suggestions? |
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| Answer Actually, medical therapy of fibroids is generally not successful in the long term. If you are having significant symptoms, you should ask your gynecologist about surgical treatment options, including myomectomy and other alternatives to hysterectomy. Hysterectomy is also an option, but you should be made aware of all possible options, including those that preserve the uterus. It is also important to make sure, if you are over 35, that the uterine lining is benign. This can be accomplished through an office biopsy or D+C/hysteroscopy in an operating room. |
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| Hormone Replacement Therapy | ||
| Question I have been on estrogen therapy for 8 years. I have uterine fibroids that have grown in the last year. I have stopped the estrogen on the advice of my doctor, and have experienced hot flashes, sweats, and lower back pain and leg cramps. Are these normal? How long will they last? I am trying this before, I agree to have a hysterectomy that is his advice. Do you have anything to add? |
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| Answer It is unusual for postmenopausal hormone replacement therapy to induce fibroid growth, although in occasional patients this can happen. I'm also assuming you are taking progesterone along with the estrogen to lower the risk of endometrial (uterine) cancer. If the fibroids were asymptomatic and there was no suspicion of cancer, growth in and of itself may not be an absolute indication for surgery in the absence of significant pain or bleeding. Your doctor appropriately may be concerned about cancer (fibroids are not cancerous, but rarely a form of cancer called a sarcoma can develop and grow, causing enlargement of the uterus). There are alternatives to estrogen in terms of managing the symptoms of menopause, but most of these have not been shown to prevent osteoporosis. In any event, it's usually a good idea to get a second opinion before consenting to any hysterectomy. |
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| Question I know of two women who had both order by their doctors to stop taking Premarin due to breast cancer. Is there any connection between Premarin and breast cancer? What can be taking in the place of Premarin? |
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| Answer The relationship, if any, between estrogen and the development of breast cancer is nebulous at best, and is a confusing issue for patients and physicians alike. Recently, some studies have come out suggesting an increased risk of breast cancer in users of estrogen replacement. Studies have gone back and forth on this issue for many years. At this time, the consensus from most medical specialty societies such as the American College of Obstetricians and Gynecologists is that no change in practice or labeling is indicated, although further research is needed to definitively establish or rule out a connection between estrogen replacement and breast cancetives, that would depend on the indications for the estrogen and any existing medical problems. Your best resource for this information would be your own physician. |
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| Hysterectomy or Not | ||
| Question I have a fibroid that is large enough to be a 7-8 month pregnancy. My doctor has permission to whatever is necessary. Should I expect to have a hysterectomy and is this the best choice? |
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| Answer In my opinion, I would hate to think that women should expect to have a hysterectomy when there may be alternatives that are appropriate in many women. If women expect to only be offered a hysterectomy, there is a real problem in gynecology. There are several issues that concern me here. First, if you have given carte blanche to your doctor to do whatever he or she sees fit, you have effectively minimized your role in your own medical care. While physicians can (and should!) make recommendations, patients should also be provided with all the reasonable options, and armed with each treatment's risks and benefits, they can make an informed choice guided by their doctors. In other words, the doctor shouldn't "decide" for you, but give you all the options and offer an opinion on which ones make the most sense medically. Second, size alone is really not a valid indication for a hysterectomy in most circumstances. Unless you are having significant symptoms such as bleeding and/or pain, intervention of any kind probably is not warranted. And there are many alternatives to a hysterectomy, some of which depend on your interests in future fertility. Third, it is inappropriate for anyone other than your own physician to indicate what is the "best choice" in this instance, since that depends on many individual factors. Hysterectomy for benign uterine disease is not an inappropriate procedure in many cases, but it is usually one of many possible options available to a woman. In other words, it is fine to choose to have a hysterectomy so long as you can make an informed decision regarding any possible alternatives. You need to speak at length with your doctor on these issues, and it is also a good practice to seek a second opinion before any major elective surgery such as a hysterectomy. |
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| Question My doctor has recommended a total hysterectomy due to a prolapsed uterus. Any suggestions for hormone treatment and what should I expect after surgery? How will the hysterectomy change my quality of life and how much recovery time is involved? |
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| Answer All of these are excellent questions, but they are best answered by the surgeon performing the hysterectomy. Any physician should discuss the appropriate risks, benefits and alternatives before any surgery, along with what to expect in terms of recovery. Hormone replacement therapy requires individualization and this should be discussed with your doctor beforehand. |
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| Menopause | ||
| Question I had a complete hysterectomy when I was 20 years old...3 months after my child was born I am having symptoms of menopause now. My question is will I go through the change again? |
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| Answer Some of your symptoms may relate to breastfeeding if that is applicable, since the hormone Prolactin can affect the secretion of estrogen, resulting in vaginal dryness and even hot flashes. Premature menopause remains a diagnostic consideration, however, and you should consult your gynecologist about ruling this out. |
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| Question I have pain in the lower side and extra fluid as you have during ovulation occur as they did when I had periods, but seem to last longer. Can you still ovulate after your periods have ceased? |
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| Answer If your periods stopped for reasons other than menopause, you can still ovulate. For example, women who have had a hysterectomy or endometrial ablation should continue to ovulate so long as they are premenopausal. In general, however, if a woman goes through a natural menopause (as suggested by 6 months without periods, and associated symptoms such as hot flashes), ovulation should not occur. You may want to speak with your doctor about investigating why you are having such symptoms. |
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| Ovarian Cysts | ||
| Question I have had lots of trouble with ovarian cysts since I was 20. I thought a cyst burst a few days ago and am now having bloody discharge. Is it normal to have bloody discharge after a cyst bursting? Also, Is there anything to be done to truly stop these cysts? How long is it healthy to be on the pill continually to stop menstruation? Couldn’t I just get a hysterectomy, if I am done having children? |
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| Answer Because in some cases progesterone levels may decrease with resolution of certain ovarian cysts, it may be normal to have an early menstrual period. Whether or not this is what is happening in your situation is best evaluated by your doctor. As far as cyst prevention-while the myth lives on that oral contraceptives prevent cyst formation, there is nothing in the medical literature to support that practice. Continuous birth control pill use can, to a major degree, limit menstruation. It is not dangerous in and of itself, nor is there any proven time limit. Whether or not hysterectomy is appropriate is up to you and your doctor, but in general it is not indicated merely to stop menstruation, especially since it is major surgery and has significant risks. You should discuss these questions with your gynecologist. |
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| Question I am concerned about my ovarian cyst (benign) and my calcified tumor. Can these be removed with laser? |
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| Answer Benign ovarian cysts (and it is impossible to say 100% that any ovarian cyst is benign in the absence of a tissue specimen) generally do not require treatment unless they persist, in which case they should usually be investigated and, in many cases, removed laparoscopically or otherwise. Laser can be used for many operations, but unless there is a specific reason for preferring the laser over electrosurgical and other methods, there is no compelling advantage to the laser in most cases (plus it's more expensive). Whether or not to remove the cyst and what I'm assuming is a uterine fibroid depends on many things that are more appropriately discussed with your gynecologist. |
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| Pelvic Pain | ||
| Question I would like to know more about embolization for the treatment of chronic pain caused by varicose veins on my uterus. Could I benefit from the embolization procedure? |
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| Answer Pelvic congestion (another term for dilated varicose veins in the pelvis) remains a controversial subject, and I probably answer 1-2 questions about this each month on obgyn.net, so you may find perusing these forums helpful in terms of previous comments. In general, there is little if anything to support the existence of such a syndrome, although individual clinical experience may vary. The entire issue has not been resolved, and so it is hard to say if treating this syndrome is useful, as it may not exist. Whether or not you would benefit as an individual patient is a judgment that you and your doctor must make based on your history, preferences and physical exam. |
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| Question What can you tell me about the risk of spontaneous rupture? Could you provide me with some references? Since the section I've also been suffering from chronic pain in the area of the incisional scar. I have no GI problems but the pain is always there. The doctor says the pain is probably due to adhesions and might clear up with careful re-sewing after a future c-section.. Laparoscopic surgery, he thinks would hold a high risk of being converted to surgery. How likely is laparoscopic surgery to help? To be converted to surgery? |
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| Answer I'm assuming you mean the risk of spontaneous rupture from a previous Cesarean section scar. It depends on the incision, although the vast majority of Cesarean sections are performed with a Kerr or low transverse incision. The risk of scar rupture during or before labor is very low, but nonzero. This is also generally true for a Krönig or low vertical scar. For classical Cesarean section scars, the risk of rupture approaches 25%, even before the onset of labor, so repeat Cesarean section is always indicated in such women. As far as adhesions, they can be treated laparoscopically, but whether or not laparoscopy or laparotomy (traditional incision) is appropriate depends on several factors including the preference and skill of the provider and level of concern for severe adhesions. Any laparoscopy can be converted into a laparotomy (incidentally, laparoscopy is surgery as well). In some cases, it is inappropriate not to convert to laparotomy, particularly if laparoscopy is a less safe or timely option. Your doctor can help you sort through all of these possibilities in your individual situation. |
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| Post-Operative Hysterectomy | ||
| Question At 43, I had a total hysterectomy, I went through several procedures, including ablation and hormone therapy. Neither worked. I still had 10 - 15 day cycles. I have 2 questions. First, I was told my uterus was larger than normal but never told what the implication of that was. I know when I was pregnant 20 years ago, they thought I was having twins but it turned out the uterus was just large. Is there something that causes this or is it normal? Second, is it normal to experience more gas after a hysterectomy? |
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| Answer It is possible that you had adenomyosis, a condition in which cells from the uterine lining grow into the muscle layer of the uterus, resulting in bleeding and pain. This is speculation on my part, however, and your doctor should be able to give you the final pathologic diagnosis. I'm not aware that gas is related to hysterectomy or any other surgery, but rather to diet. Your primary care physician may be able to give you some suggestions on this issue. |
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| Question I am a 46-year-old hysterectomy due to ovarian cysts and hemorrhaging. I have had problems with my periods since I was 10 years old. I have never had a real strong libido but since the hysterectomy there is no drive at all. have been taking Etratest, Paxil, and Synthroid for years. Is there anything that I or my doctor can do to bring back my libido because this is affecting my marriage. |
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| Answer In several studies (and more work is needed in this neglected area), hysterectomy does not affect sexual function except in those women for whom there was a preexisting sexual or psychological issue or where psychological issues arose after hysterectomy. While libido may be affected by medications, your best option is to discuss this with your doctor and inquire about appropriate counseling options for you and your partner. Help is definitely available, but it is not a gynecologic treatment. |
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| Question Four weeks ago my mother had surgery to fix a prolapsed bladder and uterus as well as a hysterectomy. Her recovery has been remarkable, with virtually no pain at all, but now she says she feels a slight "pulling" sensation in her groin. She and I feel this is probably normal, and her doctor (via phone calls to his nurse) doesn't seem to be concerned, but she is still slightly worried. Does this sound normal? Thank you for any information you can give. |
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| Answer It could be normal or abnormal, and it would be more appropriate for your mother's doctor to render that judgment. |
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| Miscellaneous | ||
| Question I have little hard round zits on my vagina. I don’t know what to call them but I have about 20. Could this be a precursor to cancer or could it be genital warts? |
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| Answer Without an examination it is not possible to say for certain, of course. It may be vestibular papillae, which are small bumps that can occur in the lower most portion of the vagina. They resemble small warts, but are not warts and are not generally caused by the human papilloma virus (the virus implicated in warts, cervical dysplasia and cervical cancer). If this is the case, they have nothing to do with cancer or warts. But a visit to your doctor is required to make that judgment. There are other possibilities as well, including warts. |
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| Question In 1996, I had an abnormal pap where Dysplasia and Condyloma were found. Later in 1999 and 2000, I had abnormal pap smears. Both times I had severe dysplasia and a LEEP was performed. Now my doctor has brought the possibility of having a hysterectomy. He did a biopsy yesterday and I am waiting the results. I haven't smoked in about 2 years and all together in my life I smoked about 7 or 8 years. Is hysterectomy the answer to make this stop? |
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| Answer While hysterectomy is certainly a definitive treatment for cervical dysplasia, it is a last resort, and more commonly done in this setting only when micro invasive cancer is diagnosed by a cone biopsy of the cervix. Other treatments such as LEEP or CO2 laser are usually more appropriate options for pre invasive disease of the cervix. Of course, this will depend on the clinical situation and what your doctor has diagnosed. You need to find out what the precise indication for a hysterectomy is, and this will depend on the biopsy. |
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| 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. |
