What will be different with periods after a tubal reversal?

It all depends. Every patient has a different experience after a tubal reversal.

The very first menstrual cycle after tubal reversal could come early, or more probably, late.  It is not unusual for the first menstruation after your tubal reversal to be heavy and painful.

Management of the pain;

• A normal pain reliever such as Motrin may provide some relief
• Prescription pain medications will be prescribed after a tubal reversal
• Feelings of weakness and fainting may be experienced

Some standard risks of the tubal reversal surgery may include bleeding, infection, anesthesia problems, and injury to other structures in the pelvis and abdomen.  These complications are extremely rare and the tubal reversal procedure is considered a very safe operation.

Patients must continue care with their regular obstetrician / gynecologist after their tubal reversal. Patients are instructed to wait at least two months before attempting pregnancy. Normal signs and symptoms and prior menstrual cycle patterns appear only if you are not having any other secondary medical problems. Regular follow-up is necessary.

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.

Viewing each menstrual irregularity individually and in detail:

Amenorrhea

Yes, even absence of menstruation is a problem.

Amenorrhea is of 2 types, primary and secondary. Primary is when the menstruation never occurs in the first place, and secondary is when it had occurred in the past but then it stops. Gestational amenorrhea is the normal absence of menstruation during pregnancy. Lactational amenorrhea is the absence of menstruation during the period a mother continues to breastfeed her child, which is again, perfectly normal. We will explain the possible causes of primary amenorrhea and secondary excluding gestational and lactational.

Primary amenorrhea

Primary amenorrhea is absence of menstruation. This may be accompanied with presence or absence of secondary sexual characteristics like breast development or body hair.

If your daughter is 14 with normal secondary sexual characteristics, she might just be a late bloomer and you can wait for a year or two. However, if there is no menarche by the time she is 16, you need to see a gynecologist. Similarly, if your daughter does not show any secondary sexual characteristics, then you need to see a gynecologist once she is 14, if there is still no menstruation. The causes are multifactorial, but quite often due to developmental problems.

The causes of the amenorrhea are mainly due to a problem in any one of the following three areas:

1. Hypothalamus
2. Pituitary
3. Ovaries

Together they form a functional endocrine axis, known as the HPO axis.

1. A. Hypothalamic reasons of primary amenorrhea:

As we have explained earlier, a very important hormone called GnRH is secreted by the hypothalamus. This GnrH stimulates gonadotropins in the pituitary gland which then stimulate the release of FSH and LH from ovaries, ultimately causing menstruation and ovulation. A decrease in GnRH release or its absence will never let the menstrual cycle occur.  When the decreased GnrH level is congenital, it is known as Kallman Syndrome.

Functional hypothalamic amenorrhea snubs GnrH levels, directly cutting LH levels and LH surge. The reasons may be over-eating, under-eating, excessive exercising, mental stress, depression, physical stress, etc.

1. B. Pituitary reasons of primary amenorrhea:

When the Pituitary gland fails to release gonadotropins in response to GnRH release by the hypothalamus, the cause clearly lies in this part of the axis. Pituitary tumors are the most common cause. Other examples in which pituitary gland causes are etiological are:

1. Cushing disease
2. hypothalamic tumors
3. Craniopharyngioma
4. Germinoma
5. Brain injury
6. Cranial irradiation
7. Empty sella syndrome
8. Pituitary infarct
9. Hemachromatoses
10. Sarcoidosis

1. C. Then we have another axis for amenorrhea; the ovarian cause:

This is usually due to defective or absent ovarian function. Deformation of gonads is called gonadal dysgenesis. Some causes are:

1. Turner X syndrome
2. Premature ovarian failure
3. Fragile X pre-mutation
4. Swyer Syndrome
5. Polycystic Ovarian disease( more known for secondary amenorrhea)

1. D. There are a few other causes as well that do not fall in either of the categories. They are:
2. Hypothyroidism
3. Hyperthyroidism
4. Sarcoidosis
5. Galactosemia

So, what about ovulation?

Doesn’t menstruation mean I am ovulating and that I can get pregnant?

Possibly. Ovulation may begin with menarche or it may not. When there is no ovulation, you are going through anovulatory cycles.

Pregnancy it has been known to occur even before the menarche. You need to understand that menarche may happen without involving the release of ova at all. The blood flow is from the uterine tissue disintegration and that may happen without ovulation. This is why you need to realize that there are many stops where essentially anything can go wrong, resulting in menstrual irregularities.

So what are the irregularities?

Anything in menstrual cycle that is not normal is an irregularity. Here are some common definitions:

No flow:   Amenorrhea

Long cycle(Infrequent):   Oligomenorrhea

Short Cycle:   Polymenorrhea

Heavy Flow:   Menorrhagia

Pain:   Dysmenorrhea

This is the usual nomenclature applied to menstrual irregularities. These are basically the descriptions of the irregularity. The underlying cause is the actual disease or Illness that needs to be treated. This is why an abnormality in your menses is worth following up. Sometimes they may be affected by vague circumstances ,but it is better to end up with a “don’t worry” diagnosis than a late diagnosis of something much more serious.

What are the vague / external circumstances?
These are numerous. Just to explain what these external factors can do, notice the following:
A.    Early onset of menarche (earlier than 12 years of age)
1.    Childhood Obesity
2.    Family Conflicts
3.    Absence of father figure
4.    Ovarian  or other tumors
B.    Late onset of menarche (later than 16 years of age)
1.    Close association with father / father figure
2.    Large family
3.    Abnormal pathology of reproductive tract

The menstrual cycle is itself affected by all these factors and more. These factors are:
1.    Stress: Family related or socially induced
2.    Sudden weight gain or weight loss
3.    Eating or emotional disorders
4.    Excessive exercising
5.    Unhealthy lifestyle i.e. smoking

What possible diagnoses can cause menstrual irregularities?
There is a wide array of possible diagnoses that we can reach depending upon the type of irregularity an individual is facing. We will discuss each possible diagnosis in further detail in the later articles in the series.

Will early diagnosis save me?
Do not assume that you have something untreatable. Having time as your ally is even better. However in order to get started on the treatment, you do need a diagnosis. Getting started as soon as possible is the best option as the majority of the illnesses can be treated medically with a good prognosis.

What is a normal period?
A normal period has the following characteristics:
A normal period is Eumenorrhea.
1.    This is a cycle of 28 days plus or minus 7 days
2.    Bleeding of 2-7 days
3.    Blood loss of 10-80 mL

When there is a deviation from this pattern, you are looking at a menstrual irregularity.

What about pain?
Some amount of pain and mid-cycle symptoms are normal. Excessive pain, intolerable pain in menstruation, called dysmenorrhea, is an irregularity.
We will discuss individual disturbances in the next article.

Now we will move to the understanding of a normal menstrual cycle.

The ovarian cycle and the uterine cycle

The ovarian cycle and the uterine cycle are two different things happening together and dependent on one another. The ovarian cycle is happening in the ovaries and the uterine cycle in the uterus. The blood flow is due to the effects of the menstrual cycle on the uterine cycle, resulting in a uterine blood flow.

It all begins with the birth of a female child. When a female child is born, she has 100,000 primary oocytes in her ovaries, waiting for puberty when they will become secondary oocytes. After that, with each menstrual cycle they take the form of ova. An ovum is a potential egg that gets fertilizes by a sperm.

100,000 oocytes mean potentially 100,000 menstrual cycles. However, that does not happen. A normal healthful female reproductive life consists of 34-35 years that can be approximately 400 normal menstrual cycles, using only 400 oocytes.

What is menarche?

The beginning of the menstruation with the first menstrual cycle is called menarche.  This is the onset of puberty and is marked by the following changes in the female body:

1.    Change in body shape
2.    Widening of pelvis
3.    Typical fat distribution
4.    Response of ovaries to the pituitary hormones with secretion of estrogen
5.    Growth of the breasts, body hair, and uterus

What is thelarche then?

Thelarche is a term referred to the 2 years preceding menarche. It primarily is characterized by development of the breasts.

Can you tell me about menstruation before we move on the menstrual irregularities?

Estrogen released by the ovary is more specifically released by a mature ovarian follicle. The follicle will cause the release of GnRH from the Hypothalamus in the brain, which will cause the secretion of FSH and LH from the brain’s pituitary gland. These hormones will induce ovulation. Once an ovum is released from a mature follicle in the ovary, it is ready to form a zygote with a sperm. If the sperm can get to the ovum through a normal fallopian tube (one that has either never been ligated or one that has undergone a tubal reversal), there is a chance of fertilization. Fertilization results in a zygote. The follicle left behind will become a Corpus Luteum and begin to secrete progesterone. This is the ovarian part of the cycle.
Now the progesterone will be preparing the uterus to receive a freshly conceived zygote. However, if that does not happen, the follicle finally dies and the uterine tissue starts disintegrating, resulting in blood flow, completing the uterine cycle.

So when do the irregularities occur?

This was a very brief summary of what happens in the cycle. There are a lot of places where things could go wrong, ultimately resulting in menstrual irregularities. We are trying to explain here what happens normally and how many processes need to happen correctly in order to ensure proper menstruation. There may be a hormonal imbalance, a born deformity in the reproductive system, absence of ovulation, or perhaps many other problems that may affect the normal menstrual cycle.

Wait, wait, absence of ovulation? If I am having menses, doesn’t that mean I am ovulating as well?

No, you may or may not be ovulating. Menstrual abnormalities, as noted above, have many causes.

I don’t understand this?

You will.
Continue patiently with the rest of the articles in the menstrual irregularities series.

Now, after much talk about perimenopause and menopause, we will take a u-turn and answer some very basic questions about your body.

The first question that brings you to us, or any physician, regarding your reproductive system is (usually) a menstrual irregularity. There might be many questions on your mind pertaining to the seriousness of the issue.

• Is my menstrual cycle telling me something about my body?
• Is an irregularity telling me something about my body?
• Do I have to be concerned about this irregularity?
• Do I need to see a doctor for this irregularity?

We will be answering all of these queries, but not right now. For that you will have to follow our series on Menstruation.

Like always, we will first begin with the basics, the menstrual cycle.

Understanding a normal menstrual cycle

What goes on in a normal menstrual cycle?

Until a few years back, one was constrained in terms of acquiring knowledge and information, sometimes irrelevant, but often very germane. Today, the internet has fulfilled this basic motive of universal access to knowledge. Educating oneself was never so easy.

This means fewer people lack knowledge about a normal menstrual cycle. However, a lot of bad information is available as well. Often there is no check on the quality of content. We believe strongly in the credibility of content, and so we will address both relevant and irrelevant questions about the menstrual cycle. You may often come across questions like “will a tubal reversal restore my normal menstrual cycle” or “will my uterus fall out after menopause.” The accuracy of some of this information, as well as the kind of information available, is not always correct.

Your menstrual cycle will not be affected by a tubal reversal (until you get pregnant after your tubal reversal). A tubal reversal does not affect your ovarian function or your uterine lining, so your menstrual cycles will remain the same.

Your uterus will not fall out after menopause… unless you have pelvic support issues. These will be addressed in another series on our blog. Uterine prolapse is an issue related to the support structures of the pelvic floor, and these are more commonly affected by genetic factors and childbirth trauma.

A menstrual cycle is a perfectly normal physiological occurrence that is supposed to happen after a female has reached puberty. More than just the cycle of monthly bleeding, menstrual cycles bring about some very essential hormonal changes which alter the appearance of a female body as well.

Only humans and some of our Darwin relatives (i.e. chimpanzees) have been blessed with the menstrual cycle. Although the rest of the mammals do have a uterus, their reproductive cycles differ and are called estrous cycles.

The main difference between a menstrual cycle and an estrous one is the show of blood. A menstrual cycle is completed with blood flow out of the body where as in an estrous cycle the bleeding is inside the body where the blood mostly stays inside the body. We hope you will not wonder about the menstrual cycles of your pet animals anymore now.

A menstrual cycle is an essential cycle required for a female before she can reproduce. Inability of a menstrual cycle to occur is read as a definitive issue with the reproductive system. We will discuss more of that and the normal physiological changes in menstruation in the next article.

Simply put, the brain produces a hormone that is transported in the blood to the ovaries. This hormone causes the ovary to produce a follicle. Inside of the follicle, an egg is developed. Ovulation is induced by another hormone from the brain sent down through the blood. Once this occurs, ovulation causes the follicle to break open and release the egg that has developed inside. The ruptured follicle (called the Corpus Luteum) will then begin to produce yet another hormone that makes the uterus a better place for the implantation of the fertilized egg (if it gets fertilized by a sperm). If the egg does not get fertilized (for example, a tubal ligation would prevent this) then the uterine lining is shed and released into the vagina. This is referred to as your menstrual cycle.