An episiotomy involves making a surgical incision to assist in vaginal delivery by enlarging the birth canal.

Most are done in 2 ways:

1. Medio-lateral episiotomies are either a right or left side vaginal cut. This will engage more muscles, have deeper tissues involved, it take longer to heal.
2. Midline episiotomies are intended to be a cut straight down cut to the anus, but avoiding the anal sphincter and rectum.  This is less extensive and generally heals faster.

How much time needed to heal an episiotomy?

Typically episiotomies heal within about 10 to 14 days depending on the degree of the laceration and other variables.

A 1st-degree incision is just a slight cut that does not go all the way into the perineal muscle.  A 2nd-degree incision, a little deeper, is a common practice that cuts into the perineal muscle but not completely through the muscle.  A 3rd-degree incision actually cuts through this muscle, but not through the round sphincter muscle that is next to the anus. As the repair of injuries to this muscle may prevent fecal incontinence, it is of extreme importance to have a skilled and experienced physician such as Dr. Morice do the repair. A 4th-degree tear is a severe tear extending into the rectal tissue and possibly involving periurethral and labial areas.  It must be repaired appropriately to prevent a hole forming between the vagina and rectum.  If not done properly, the hole may convert to a fistula, where gas and feces can pass into the vagina. This can be repaired surgically even years later, however can be avoided by a good surgical repair by an experienced and skilled physician.

Long-lasting pain from an episiotomy may result from:

1. A hasty repair.
2. Not having sufficient visualization of the area repaired during the repair.
3. Excessive bleeding.
4. A moving target (a patient who constantly moves while doing the repair).

Outcomes after episiotomy include:

1. Severity of perineal laceration related to continued pain
2. Fecal or urinary incontinence.
3. Pelvic floor outcomes such as pelvic floor relaxation or prolapse

What measures should be taken during episiotomy?

1. Skillful repair in order to minimize pain and assist healing.
2. Postpartum inspection if any complaints to discover any other damaged areas of the vagina, cervix, perineum or anus.
3. For immediate reduction in pain, injection with numbing medicine in the area or IV administration of pain medicine as needed.
4. Kegel exercises to increase blood flow to the area may improve healing.

What are the risks and benefits associated with episiotomy?

The following risks are frequent;

1. If the area is not approximated with good surgical technique, the wound edges may not heal easily.
2. Tight suture healing leads to formation of granulation tissue, spotting, and pain in some cases.
3. A poorly healed end may be formed after an episiotomy, usually at the 6 o’clock position at the base of the vagina.  It causes severe pain with placing of a tampon, finger, or penis.
4. Significant increase in maternal blood loss is another risk.
5. A deep or extensive episiotomy may lead to intrapartum hemorrhage (excessive blood loss).
6. The risk of an anal sphincter injury is increased with the most commonly performed midline episiotomy.
7. The risk of poor wound healing is increased in a breast-feeding mother due to a decrease of estrogen levels in breast-feeding moms.
8. Vaginal discomfort and pain due to vaginal dryness caused by decreased estrogen levels in breast-feeding moms.
9. The amount of pain in the first several postpartum days is mostly underestimated.

Benefits include that episiotomies reduce anterior vaginal lacerations, which carry nominal morbidity.

Prevention of intracranial hemorrhage or intrapartum asphyxia, as well as birth trauma, is the main advantage of an episiotomy.

What is the greatest risk encountered during episiotomy?

Mediolateral and, to a minor degree, mid-line episiotomies considerably increase the quantity of blood loss at delivery.  Blood loss and possible anal sphincter damage are the greatest risks during episiotomy.  The most severe and underestimated is the anal sphincter damage, particularly with the midline episiotomy.  The rate of recurrence and severity varies from case to case. To determine the risk factors for anal sphincter injury during episiotomy, a great deal depends on variables such as vacuum assistance delivery of the newborn or delivery with forceps, as well as individual obstetric factors such as fetal weight, maternal pelvis and medical conditions, and the position of the fetus.

Vaginal dryness occurs mostly due to a hormonal imbalance in the female reproductive system as well as in the tissues and membranes of the vagina.  This symptom is mostly associated with menopause.  Additional causes of vaginal dryness are childbirth,  breastfeeding, stress, birth control pills, medications, and other less common gynecological problems.

Symptoms include painful urination, sudden depression, itching or burning sensation or any other strange physical symptom, and pain or difficulty in having sex.

Why birth control pills causing vaginal dryness?

Among the side effects of taking contraceptive or birth control pills, the most common is vaginal dryness.  The vagina may lack the normal amount of natural lubrication. Although this is a normal side effect, itching or burning sensations, and difficulty having sex, can make life uncomfortable.

Pills actually have less estrogen than your own body would produce during an average periodic cycle. It does not allow your body to produce the normal level of hormones. Therefore, birth control pills may simulate menopausal effects by disturbing the natural hormonal level.

The contraceptive pill is made from progestin or a combination of progestin and estrogen. It affects vaginal moisture towards dryness by many ways.  First, most pills keep the estrogen level at almost the same low amount throughout the month in contrast the body’s natural ovulation cycle. A higher level of estrogen is important to maintain the normal mucus production in the vagina.  Second, while avoiding ovulation, the pill reduces the cyclical production of testosterone for libido. Decreased libido is the direct cause of the body’s decreased ability to respond sexual desire. Having less sexual desire leads to less lubrication in the vaginal area.  Third, pills having a low-dose of estrogen may not provide sufficient estrogen to maintain lubrication in the vaginal area. And finally, the estrogen in the pill causes an increase in a hormone (SHBG) that actually removes testosterone out in the circulation, leading to decreased libido and less vaginal lubrication.

What are solutions to minimize vaginal dryness using birth control pills?

During sex, use of a water soluble lubricant (any slippery aid like KY jelly or Astroglide) may help.

Change your dose of birth control as most pills are available with a 20, 30 or 35 microgram dose of estrogen (ethinyl estradiol), combining a dose of a progestin. Switch to a 35 mcg pill if using 20 mcg pills or use a high dose 50 mcg pill for a few months.

Oral estrogen for a few days a month for a short time after consultation may also be helpful as pills are having low-dose of estrogen may not be providing a sufficient amount of estrogen.

Drink more water and try to avoid dehydrating beverages like tea, coffee, and alcohol.

Use a multivitamin, exercise, and eat a balanced diet.

Does having a Tubal Ligation or a Tubal Reversal affect vaginal dryness?

Some women who have had a tubal ligation complain of a post tubal syndrome that includes vaginal dryness as well as other symptoms. Tubal reversal, specifically microsurgical tubal reanastomosis, can help these women who suffer from post tubal syndrome. The mechanism of why this occurs is not entirely clear, but for some patients tubal reversal is an option worth exploring.

When does the Perimenopause interval start?

Perimenopause is a natural part of aging, the interval in which you are in a transition leading up to menopause.  It signals the ending of your reproductive years.  In most women, perimenopause can occur two to seven years before menopause. As the average age of a non-smoking American female is 51 (smokers average 49), the perimenopause usually starts in the mid to late 40’s.  The duration varies from two to eight years including the first year after your final period.  Remember that a whole year without a period before menopause is also considered part of perimenopause.  Always let your doctor know when you had gone a whole year without a period as you are entering into the menopause phase of your life.  Basically, this stage compromises of gradual falling and fluctuating hormone levels with associated symptoms.

What are the symptoms of Perimenopause?

This can be very normal to very severe in some cases. 70% women are affected by the typical symptoms of perimenopause. Symptoms occur as some follicles respond to hormonal change and high estrogen levels.  Periods can change, space out, or even come closer together.  The amount of flow can be heavier or lighter, and may shorter or longer.

The most typical symptoms due to falling and fluctuating hormonal levels are:

1. Hot Flashes.
2. Night Sweats.
3. Irregular Periods.
4. Loss of Libido.
5. Vaginal Dryness.
6. Mood swings.

Other symptoms of change in behavior, body, or emotions may develop in most women, including:

1. Fatigue.
2. Depression.
3. Anxiety.
4. Irritability.
5. Breast pain.
6. Joint pain.
7. Hair Loss.
8. Memory Lapses.
9. Sleep Disorders.
10. Incontinence.
11. Concentrating Loss.
12. Dizziness.
13. Weight Gain.
14. Bloating.
15. Allergies.
16. Brittle Nails.
17. Osteoporosis
18. Irregular Heartbeat.
19. Increase in Facial hair.
20. Urine Incontinence.

The severity of above symptoms depends on how you prepare for and treat this new phase of your life.

Do patients who have had a tubal ligation or a tubal reversal have an earlier onset of Perimenopause?

Previous tubal ligation or subsequent tubal reversal will most likely not affect the age of perimenopause. On occasion, a tubal ligation may interrupt the normal blood flow to the ovary on one side or another, but this is rare. If the blood flow to an ovary has been affected, the ovary may fail earlier and this may lead to an earlier perimenopause.

A tubal reversal will not restore normal blood flow to an ovary, if this disruption has occurred. A tubal reversal strictly restores normal flow through the fallopian tube and this does not affect the age of onset of perimenopause.