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.

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.

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.

Heavy menstrual bleeding and clotting are common problems for many women. When women need to change three pads or tampons every hour, then they may be losing too much blood and they urgently need to be checked by their gynecologist. A complete pelvic exam and ultrasound will be performed. This may be the indication of some serious problem as well. It may be just a hormonal change that has occurred after a major surgery like a hysterectomy, or a minor surgery such as a cystectomy or tubal reversal.

It could be due to polyps in the lining of the uterus or fibroids within uterus or condition where the walls of the uterus become thick because of gland growth from the lining. This is called adenomyosis.

Fibroids in the uterus are tumors. These tumors are by far the most common kind tumor of the uterus. The symptoms of fibroids are pelvic pain, increased menstrual cramps, increased menstrual flow, blood clots, irregular or painful periods, urinary frequency, constipation, and bloating

If your periods are on the heavy side but repeat in a regular pattern on a cyclical basis, that would be considered normal for you. Or, if you have some irregularities in your flow that dissipate the following month, there is probably nothing too serious going on.

Often bleeding can be reduced by either the birth control pill, the Mirena IUS (a progestin IUD) or, if necessary, surgery to remove the polyp or fibroid. There are also procedures in which the lining of the uterus is destroyed with heat freezing or laser (endometrial ablation) that can decrease or stop bleeding.