How do gynecologists proceed with diagnosing Ovarian Cysts?

Although we do not see an increase in the rate of ovarian cysts after tubal reversal surgery, polycystic or simply cystic ovaries are one of the concerns some patients have expressed after tubal reversal surgery. For most, a thorough exam after the tubal reversal surgery, or close monitoring after the tubal reversal surgery will alleviate these fears.

Predicting whether a cyst is benign or malignant is not always straightforward.  Clinical examination, serum concentrations of CA 125, and ultrasonography are the main diagnostic protocols available.

Clinical examination is often unsatisfactory, with 30-65% of ovarian tumours being unnoticed and mostly overlooked by most doctors.  Ultrasound studies of ovarian cysts will however confirm the presence or absence of cysts in nearly all cases. Combined with a pelvic exam, this will lead to diagnosing close to 100% of all cysts.

Vaginal ultrasonography is the most widely performed and accurate procedure for prediction of the benign nature of a cyst.

How do Gynecologists conduct the evaluation?

1. Gynecologists first take a detailed medical history of the patient and perform a physical examination.  During the physical examination the gynecologist will perform a pelvic exam.

2. In a pelvic exam the gynecologist will place an instrument called a speculum into the vagina and will examine the vaginal walls and the cervix. The gynecologist may take samples of vaginal discharge or perform a Pap smear (removing cells from the cervix with a small brush). Samples are sent to a laboratory for microscopical examination.

3. The gynecologist will then do a bimanual exam by inserting two fingers into the vagina and placing the other hand on the abdomen to examine the size and shape of the uterus and ovaries.  The ovaries may feel larger than normal and this exam may make the patient have discomfort.  If cysts are felt, the gynecologist will suggest additional laboratory and diagnostic tests.

4. Laboratory tests mostly include;

a)        a complete blood count (CBC) and a WBC to perceive any infection and internal bleeding,

b)a pregnancy test to identify uterine pregnancy or ectopic pregnancy.

5. Diagnostic tests include an ultrasound, Doppler studies, Vaginal ultrasonography, and if needed, an x-ray and laparoscopy.

6. An ultrasound test mostly able to shows size, numbers and what the cysts are made of.  If the patient having the cyst is consisted of solid materials or a combination of fluid and solid materials, the gynecologist may suggest an x-ray to find whether it is a benign cyst or a malignant tumor.

7. Gynecologists may recommend later an additional diagnostic test that is laparoscopy if he suspects endometriosis having the cyst enlarged much without fluid.

8. Laparoscopic procedure involves the placing of a laparoscope (a narrow tube with a fiberoptic light at one end) into the lower abdomen.  This is done via a small incision just below the navel to detect the ovaries.  Next if the gynecologist feels the necessity, he may drain the fluid from the cyst, or he can remove the cyst entirely.

Would cysts be discovered during a tubal reversal surgery?

Yes – if you have cysts on either ovary during your tubal reversal surgery, Dr. Morice can remove the cysts at no additional charge.

Why is the diagnosis important?

The search for a diagnosis to explain ovarian cysts should be done with complete awareness of all of the possibilities.  Ovarian cysts can result from a devastating process such as ovarian cancer, or may be simply normal, enlarged follicles in a young patient who is ovulating. The reason for the cyst(s) must be determined in order to provide appropriate medical care.

Do cysts cause problems?

Most ovarian cysts are small and do not cause problems, especially if a woman is in its natural reproductive age. However, larger cysts may cause problems even if they are simply reproductive (physiological) cysts.  Pain and swelling with bloating in the abdomen are the first signs.  A simple pelvic exam can provide information about the size of the cyst(s) and their location. An ultrasound exam can determine the exact size and the relative likelihood of the cyst being a normal, reproductive cysts versus a potential cancer.

Some tests to help the diagnosis include:

1. Radiographic tests including ultrasound, CAT scan, and MRI.
2. Clinical pelvic examination
3. Laboratory tests including CA-125 serum concentrations.  In almost 70% of women who have benign ovarian cysts, the concentration is within average limits.  For malignant cyst(s), there were higher concentrations of serum CA-125 identified.  Unfortunately, 30-65% of ovarian tumors cannot be identified by serum CA-125 concentrations.
4. Vaginal ultrasonography is considered the most accurate modality for diagnosis. In most cases, the prediction of a benign versus a malignant cyst is possible.
5. Ovarian cytology is a very reliable way to know the state of ovaries.  Fluid can be withdrawn from the ovary and sent for special tests.
6. Ovarian pathology – this is the definitive method of determining if the ovary is benign or malignant, but of course this requires a biopsy or removal of the ovary.

Polycystic ovaries are one of the concerns for patients after tubal reversal. Even after a tubal reversal surgery, some patients will have problems with ovarian cysts that cause them to have difficulty in getting pregnant. Some women may not succeed in becoming pregnant after tubal reversal surgery because they do not ovulate regularly. This can be due to cystic ovaries. After tubal reversal surgery, close monitoring is needed to evaluate the fertility of women who have difficulty getting pregnant.

Female fertility is controlled by reproductive hormones. An imbalance in these may cause an inability to ovulate (release an egg) called anovulation.  Anovulation may lead to symptoms of a hormonal imbalance, or possibly a woman may not ovulate due to a hormonal imbalance.  This cyclic balance between hormones is needed for fertility in women.

After menopause, imbalance is normal due to the aging process. For some younger women, even in their thirties or younger, symptoms of early onset of these hormonal imbalances and the associated disorders has become more and more of a problem.

What factors may present in young female patients?

Hormonal imbalance may be dependent on some continuing factors in a woman’s life, such as:

Nutrition or lack of it,

Basic diet imbalance,

Environmental reasons, including pollution,

Stress,

Contraceptive and birth control medication,

Exercise or lack of it,

Above average consumption of non-organic foods,

Animal products that have disproportionate amounts of estrogen,

Anovulation.

Anovulation may lead to the significant problem of disturbing hormones.  When a woman is not ovulating it means she may be producing too little of one hormone, and/or too much of another.  The production of progesterone from the ovaries does not take place during an anovulatory cycle.  The direct cyclic result is that the normal value or level of progesterone starts to decline. Also, the estrogen level starts to rise.

Note:  The amount of these hormones produced in a woman’s body can fluctuate from one month to the next even in healthy women, but is that there is an incorrect relationship between progesterone and estrogen levels which may lead to infertility.

Some surgical procedures may affect one’s ability to ovulate for a short period of time. For example, after a tubal reversal some women may undergo a temporary phase of hormonal imbalance between progesterone and estrogen levels. This will resolve as the body recovers from the tubal reversal.

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.

Once you have entered menopause, you will find yourself free of most of the symptoms of pre and peri-menopause, particularly the menstrual problems i.e. irregularity, heavy flow etc. Not only that, but you may even find yourself more energetic and present-minded than in past 5-6 years during peri-menopause.

So you may ask now, if I have overcome of all the symptoms, what exactly is the big deal about being menopausal?

How long does this post-menopause state go on? Forever?

Technically speaking yes, even if you die at the ripe old age of 120, you are still in menopause, but that does not mean that you are still experiencing symptoms. For example, you can still call yourself postpartum years after your child’s birth because technically you are post-partum.

So what is happening to my body in postmenopause?

Your hormonal levels are juggling in order to settle on a fixed level. If you get your FSH levels tested, you will find a higher level of FSH. This means that more FSH is being produced by the pituitary gland, going into an overdrive, in an effort to stimulate follicular formation in your ovaries. This is indeed a futile attempt on the part of the pituitary gland.

Will I have a high level of FSH throughout my life? Isn’t that dangerous for my health?

Yes, you will have a sustained high level of FSH throughout your life, but this is not dangerous at all. It causes no harm. However, if you go for hormone replacement therapy, this high level of FSH will come down.

Are there any other hormonal differences apart from FSH?

Yes, your estrogen production has changed its production site.  While you were in premenopause, estrogen was primarily produced in your ovaries all your life. However, when in menopause, your fat cells take the major role of production of estrogen.

What if I undergo a hysterectomy before menopause?

If you also have your ovaries removed, you will then bring your body into a surgically induced menopause. The effects will still be the same as if your ovaries quit working in a natural way, but the effects will be sudden rather than gradual.

Can a tubal reversal accelerate menopause or perimenopause?

No, tubal reversal surgery is not related with the onset of menopause in any manner. If you are looking to reverse your tubal ligation, do not consider menopause as a risk of tubal reversal surgery.

Are my bones and teeth going to be affected?

There is a potential to develop decreased bone mineral density after menopause. You should continue to follow a healthy lifestyle and have this condition screened on your visits to Dr. Morice. Osteoporosis is a risk that we all face as we age. As such, it is of utmost importance that women adopt a healthful lifestyle, especially before menopause. However, if you have not done so earlier, it is never too late.

You need to develop positive habits and get rid of negative ones i.e. smoking, excessive drinking, overeating etc. You should also take a minimum of 1000 mg of calcium per day in order to avoid significant osteoporotic changes.

There are many nutrient supplements available in the market. Make sure you take adequate vitamins, especially vitamin D and calcium.

You should also work out and exercise regularly. It does not have to be a vigorous routine, but a 15-minute daily walk can do wonders.

Is adjusting to menopausal life hard?

Not at all! It is the peri-menopause that gives women the most trouble. By the time you are in menopause, most of the dreadful peri-menopausal symptoms are gone. You are no longer irritable or moody since you have had ample time to adjust physically and mentally to the end of menstruation. The childbearing years are long gone and you have more time to spend on yourself, your health, and your body. Most of the career women are now settled comfortably into their professional lives and the earlier professional stress is often dissipated as well.

Menopause, for many, is actually the beginning of a life free of stress and tension. Menopause often marks the beginning of a new era in a woman’s life, where she can now concentrate on her own well-being.

Menopause is still considered a taboo subject and is not open to public discussions. Women find it easier to rely on word of mouth than consulting an authority on the subject. Some even look at menopause as a dreaded evil.

Through this section we will try to cover as many random queries related to menopause as possible. These include home remedies as well as issues like pregnancy and menopause.

I am taking hormone replacement therapy. I still experience lethargy and stress. Why?

That is quite a normal occurrence. This also depends on the type of therapy you are taking. Many women find progestin-only therapy much more suitable as compared to a combined pill. As for the stress, you might benefit from lifestyle changes, coping mechanisms, or other medications. Consult Dr. Morice for further advice.

What can I do, without medications, in order to ease the symptoms of menopause?

1. Take better care of your body. It may sound a little trite, but this may offer protection from all sorts of illnesses as well as postmenopausal symptoms.
2. Eat well. Make sure your daily intake of calcium and iron is adequate, since menopause effects bones too. A fiber-rich diet that is low in fat is best.
3. Go for supplements. If you think you cannot cover essential nutrients like calcium or vitamins in your normal diet, take supplements.
4. Exercise regularly. Walk daily. Do cardio exercises for your heart. Try investing a few minutes a week in Yoga or Pilate.
5. Remove stress-inducing factors from your life. Work out the stressful aspects of your life and get rid of them for once and all.

Is pregnancy possible once I am into perimenopause?

Yes. Although not common, it is known to occur. Unless declared menopausal, you can never rule out the possibility of a pregnancy. Make sure you take adequate contraceptive measures if you are not interested in getting pregnant.

I have been having recurrent vaginal infections ever since I entered perimenopause. Are the two related?

There is no direct causal relationship. You may have read earlier, that in perimenopause, there is direct effect on urogenital system and vaginal dryness too. This dryness can be a precipitating factor in vaginal infections, however, menopause does not predispose you to infections in any way.

Is menopause known to be related to neurological disorders?

No. There is no known association of menopause or perimenopause with neurological disorders. However, since this is quite a stressful period in a woman’s life, stress, depression, mood swings, and other psychiatric complaints do occur quite frequently. Many also complain of lack of concentration and a preoccupation with these symptoms.

Does one put on weight in menopause?

Quite a few times, yes. But a lot of it is due to depressive binging of food and lethargy. If you eat healthy and work out regularly, there is no reason why you should put on weight in menopause.

How does one get surgically induced menopause?

Removing the ovaries (oophorectomy), which often occurs with hysterectomy, will result in surgically induced menopause almost immediately. Other procedures such as tubal ligation or tubal reversal do no cause menopause.

Does any clinical condition induce menopause?

Yes, with premature ovarian failure, there can be early menopause.

Understanding your normal physiology

There are numerous popular fads regarding menopause. Some, like getting a tubal reversal after 5 years of tubal ligation can induce menopause, are absurd, while others, such as hot flashes, are certainly true. In order to understand this and pick the truths from the myths, you need to go a bit deeper into the physiology of normal menopause.

An oocyte is an immature cell in the ovary.  A primary oocyte is formed in the ovaries of a woman before her birth. It becomes a secondary oocyte after the onset of menarche (the first menstrual period). This oocyte then becomes an ovum, which is released from the ovary during ovulation and perhaps fertilized by a sperm to form a zygote (a future embryo which then develops into a fetus).

When a female child is born, there are up to 100,000 oocytes in her ovary. Only about 400 are used in her reproductive life. Normal menopause occurs when these oocytes become depleted or non-functional.

A typical menstrual cycle occurs in fixed phases under the effect of various hormones. The following is a simple summary of a menstrual cycle.

A Regular Menstrual Cycle

Follicle Stimulating Hormone FSH and Luteinizing Hormone LH are secreted by the anterior pituitary gland. They are both released under the effect of gonadotropin releasing hormone (GnRH). This GnRH is released by the effect of Estrogen, yet another hormone. This estrogen is released by a mature follicle during the follicular phase. This follicle contains a primary oocyte. When the size of a follicle is big enough, the estrogen triggers a sudden release of LH. LH in turn helps in maturation of the oocyte into secondary oocyte and finally ovum, and it is released from the follicle in the ovary during ovulation. The empty follicle left behind is now called a corpus luteum.  This does not get destroyed right away but persists for some time in the ovary, releasing progesterone.  The progesterone makes a uterus receptive for an embryo to be implanted. This corpus luteum also releases inhibin, which inhibits or suppresses the release of FSH and LH temporarily. The unfertilized egg must then travel through the fallopian tube to reach a sperm coming through the tube from the uterus. (A tubal ligation would prevent this meeting of the egg and the sperm, and a tubal reversal could repair the ligated tube so that the egg and sperm could meet again). If they meet, and fertilization then occurs, the embryo is implanted in the uterus and forms a placenta. The placenta releases hCG which causes the corpus luteum to continue to release progesterone. In case of no fertilization, this corpus is reabsorbed and disappears in most cases. As there is no progesterone now, the mucosal lining of uterus gets destroyed, initiating menstrual bleeding. The effect of inhibin is lifted from FSH and LH, and the increase in FSH causes formation of more follicles to start the process again. Only one follicle matures to become the dominant follicle, the future corpus luteum, holding the primary oocyte.

So this was a normal menstrual cycle, when is normal menopause?

A primary follicle produces estrogen. With age, the oocytes become non-functional. As a result there are fewer primary follicles, reducing the levels of estrogen in the body. Without estrogen there will be no LH surge and no ovulation. No ovulation means no progesterone. That means general thinning of uterine mucosa, vaginal atrophy, and erratic menstruation. Furthermore, the perimenopausal symptoms that you experience i.e. insomnia, irascibility and headaches are due to the lack of estrogen. Post-menopausal urogenital symptoms and osteoporosis are also due to this low level of estrogen. Hormone replacement therapy is often prescribed to cut down the incidence of such symptoms.

Can menopause be induced?

Yes, a hysterectomy can induce menopause if the ovaries are also removed. It will then be called surgically induced menopause.

Will any surgery performed on my uterus induce menopause?

No. Except for removing the ovaries, or some brain surgeries, there are no other surgical procedures that will induce menopause. Neither tubal ligation nor tubal reversal has any effect on menopause.

Although we started with tubal ligation, we will proceed with this health education in a systematic fashion. The reason we wrote about tubal ligation before anything else is because we received most of the queries pertaining to tubal reversal, the symptoms and other associated areas.

We have decided to cover the vast area of menopause in various educatory sessions in a similar manner and hope to satisfy the curiosity of our loyal readership.

Comprehending Menopause

More than anything else, women need to learn about menopause in a much more detailed way than ever before. Even their male counterparts need to know about this so that they will understand what it is that women must endure.

Menopause is mandatory. Whether you like it or not, it is going to happen. It is nature’s way of relieving the women of their childbearing labor and giving them official rest. You can choose to enjoy this phase of your reproductive life, or worry endlessly because of countless unanswered questions.

Rather than avoiding discussing it, menopause should be embraced with an open heart and mind.

Clinical view of Menopause:

The verbatim definition for a layman:

Menopause is “the permanent cessation of menstruation, occurring usually between the ages of 45 and 55”.

A clinical definition of menopause which you all should know is:

Menopause is one day- the date when 12 months have gone by since your last period.

When you hear people around you, saying that X or Y is going through menopause, what they are actually referring to is perimenopause. Perimenopause is truly the span of transitional years around the last period ever, both before and after. Perimenopause can be understood in 2 phases.

1. Pre-Menopause
2. Post-Menopause

Together, they can be referred to as perimenopause or as the general public sticks to saying, menopause.

Around what age is usually perimenopause and menopause expected?

Where majority of the women undergo perimenopause between 45-55 years of age, variants have been noticed. We have seen as young as 34 and as old as 64 to undergo perimenopause, however such cases are rare.

When explaining about a medical condition such as menopause or perimenopause, we usually stick to the normal age range of the state, and hence in this case we will talk of the 45-55 years bracket.

Exactly how do I know I am in the brackets of Perimenopause?

If you are above 40 years of age, are experiencing a marked difference in your usual menstruation pattern and are having the trademark “hot flashes” and night sweats, it is highly probable that you have entered the perimenopause.

Do not account mood swings for the diagnosis since they alone are a highly undependable factor and have a multifactorial origin.

Is there any way I can delay it?

Menopause is nothing to be ashamed of, or to be delayed. It is as natural a change as menarche, the onset of menstruation. You only need to take care of yourself and your body. This change is important since as you grow older, your body loses the kind of power and energy required for carrying a pregnancy as well as a laborious child birth.

You may hear all sorts of false suggestions to delay menopause, like hysterectomy, tubal ligation, tubal reversal, or hormonal therapy, but this is inevitable and should be anticipated and prepared for, instead of against.

Embrace it instead of fearing it.

Vaginal atrophy can affect women of all ages but it is more common that women between the ages of 40 to 59 will suffer from dryness, itching, and burning related to vaginal atrophy. In the top ten afflicting problems of menopausal women, this is often at the top of the list. It is not expected or predictable. Vaginal dryness is because of many reasons. In younger women, dryness can be caused by birth control pills, surgical treatments (like cystectomy or tubal ligation), emotional issues, and multiple other medical conditions.

Vaginal dryness is often experienced when there is a lack of vaginal lubrication, often caused by a lack of estrogen production. Some will develop female sexual dysfunction which can cause one to dread intercourse and to avoid sex. Intercourse can be very painful. These women may also experience libido problems as well. Hormonal imbalance is also the cause of vaginal dryness, as well as chronic yeast infections, bacterial infections, or some kinds of cleansing of the vagina.

Many couples use condoms and foam or a method that involves a gel of some kind. Birth control pills sometimes do not provide the required level of estrogen and production of testosterone to maintain vaginal lubrication and necessary libido.

To resolve these issues there are many steps which can be followed. Use of a water soluble lubricant like Astroglide may be helpful. Estrogen therapy is useful if there is only vaginal dryness. Women who use vinegar, bubble baths, hand lotions etc can cause this dryness to become more complicated and lead to infectious.  Use of multivitamins or mineral supplements can be useful as well. Balanced diets can and proper nutritional intake can help maintain a healthy lifestyle and reduce some of the complicating issues surrounding vaginal dryness.

Many women who don’t want to have babies for the rest of their lives permanently they go for tubal ligation surgery. After tubal ligation women experience many side effects in which hormonal changes are the one most common. But with the change in life circumstances, some women want their own babies they want to reverse the process. Many will elect to undergo a tubal reversal. Other than having their own babies, women will proceed with a tubal reversal for many reasons. Women who undergo the process of tubal ligation may experience irregular and painful periods, vaginal dryness, menstrual related problems, trouble sleeping, hot and cold flashes, loss of libido, early onset menopause, mood swings, palpitations etc To resolve some of these issue they seek out a tubal reversal. While tubal reversal my not be the best solution for these problems, some women find that a tubal reversal procedure may help them feel more psychologically sound. Many will attribute a tubal reversal with the resolution of some of these complaints.