After a hysterectomy there are no more periods and it is not possible to become pregnant. A total hysterectomy involves removal of the cervix and the body of the uterus only. If a woman is premenopausal and the ovaries are free from disease, they are usually preserved and the patient will not require hormone replacement therapy following surgery. Cyclical symptoms such as sore breasts and mood swings may continue. If the ovaries are diseased or after the menopause, the tubes and ovaries may be removed. This is referred to as a total hysterectomy and salpingo-oophorectomy.
WHAT IS ENDOMETRIOSIS? Endometriosis is a condition in which endometrium-like tissue grows in locations outside the uterus. These are often called endometriosis implants or lesions.
HOW COMMON IS ENDOMETRIOSIS? Endometriosis may affect women at any time during the menstruating years (from puberty to menopause). It is estimated that 10 to 15% of women may have this condition.
WHAT ARE THE SYMPTOMS OF ENDOMETRIOSIS? Endometriosis is a common cause of period pain, chronic pelvic pain and infertility.
The symptoms of endometriosis are quite variable and may fluctuate in severity from time to time in the same person. Both severity and types of symptoms may not correspond to the extent and locations of the disease.
"Irregular periods are the most common endometriosis symptoms"
HOW IS ENDOMETRIOSIS DIAGNOSED? Endometriosis can be suspected on the basis of symptoms. Pelvic examination may allow doctors to detect the scar tissues caused by the implants. Ultrasound may show the presence of cysts inside the ovaries (chocolate cysts) which occur in 10% of women with endometriosis.
At the present time, the only way to confirm the presence of and to check for the extent of endometriosis is by laparoscopy. This is a day-only examination in hospital, under general anaesthesia, in which a small telescope introduced through a small incision at the umbilicus allows doctors to directly see endometriosis.
Despite increasing awareness, research has shown that it still takes on average 8 to 9 years from the onset of first symptoms to the time a diagnosis is confirmed. This often means years of unnecessary suffering and delay in appropriate and effective treatments.
Early diagnosis remains the key to successful treatment for endometriosis and prevention of its long term complications.
What are fibroids? Firboids are slow-growing tumours found in the uterus. They may be found in in the outer layer (serosal), the middle layer (intramural), or in the inner layer (submucosal) of the uterine wall, and may protrude partially or wholy into the uterine cavity (pedunculated).
Fibroids are almost always benign. Malignant or cancer change in fibroid, called leiomyosarcoma, is rare, with estimated incidence of 0.2% of uterine fibroids. At present, there are no reliable clinical, imaging or blood tests to distinguish between a fibroid and a leiomyosacrcoma. The diagnosis is from histology after the fibroid or uterus has been removed.
How common are fibroids? It is estimated that 30 to 70% of women of childbearing age may have fibroids, making them the most common tumours of the uterus.
What are the symptoms of fibroids? The majority of women who have fibroids do not have any abnormal symptoms. Therefore, most women are not aware of their presence and may never be troubled by them. More often than not, fibroids are incidentally detected on routine pelvic examination, ultrasound check during antenatal screen or for abnormal bleeding.
Symptoms which may be due to fibroids include: abnormal bleeding - prolonged, heavy menstruation pelvic pressure or discomfort bladder symptoms - frequency, voiding difficulty bowel symptoms - constipation, abdominal bloating pain - backache, lef pain, rarely severe pelvic pain (due to acute torsion, degenerative changes, fibroid expulsion through the cervix)
In general, locations (submucosal, intramural, serosal), size and number of fibroids strongly determine the types and chance of developing symptoms.
What problems can fibroids cause? Anemia - from heavy menstrual blood loss Bladder problems - incontinence, frequency, voiding difficulty Constipation Pain - back, leg, abdomen Infertility, recurrent miscarriage, pregnancy complications - submucosal fibroids may distort the endometrial cavity and affect sperm and egg interaction or implantation. This may result in infertility or miscarriage. Large / multiple intramural fibroids may increase the risk of fetal malpresentations or premature labour. Malignant cancerous change - uncommon, mostly unpredictable. Growth of fibroids after menopause should raise suspicion/concern of malignant change.
When should fibroid be treated? Firboids may need to be treated if one or more of the above-mentioned clinical problems become troublesome.
The following tests/investigations may help your doctor decide if your fibroids require treatment:
Ultrasound - pelvic or transvaginal Hysterosonography - where saline is instilled into the uterine cavity Hysterosalpingogram - an XR imaging test after dye is instilled into the uterine cavity and the fallopian tubes Hysteroscopy - using a small telescope to directly examine the uterine cavity Laparoscopy - using a small telescope to examine the abdominal and pelvic cavity through a small incision at the umbilicus. Apart from assessing fibroids, this technique also checks the ovaries, the fallopian tubes and conditions such as endometriosis
What treatments are available? For most women who are asymptomatic, a wait-see expectant management is often advised. For women with symptomatic fibroids, the treatment options include: Mirena IUD or hormonal medications (progestogens, GnRH-agonists) - help control or reduce heavy menstruation Myomectomy - hysteroscopic surgery (submucosal fibroid), laparoscopic or abdominal surgery for large intra-mural or serosal firboids. Potential complications of myomectomy include bleeding, blood transfusion, hysterectomy, infection and adhesions. Where large fibroids are removed, uterine wall weakness may occur . This may mean increased risk of uterine rupture in late pregnancyor during labour. Due to this risk, elective C-section may be advised to avoid / reduce the risk of uterine rupture. Hysterectomy - a permanent solution, major surgery, loss of ability to bear children, loss of menstruation. The cervix and the ovaries can be preserved. The surgery can be either by laparoscopy or abdominal surgery. Uterine artery embolisation (UAE) - interventional radiologists inject small particles via cannula to block the blood vessel(s) supplying the fibroid(s). Evidence suggests UAE is effective in reducing heavy bleeding and shrinking fibroid volume. Minor complications include pain, fever, nausea, vomitting, ,malaise. Reported serious complications include serious infection (1%) and ovarian failure (4-14%). Uterine artery occlusion Myolysis - using laser, electric current or liquid nitrogen to destroy the fibroids. Safety, effectiveness and outcomes are unconfirmed. MRI-guided focused ultrasound - using high-frequency, high-energy ultrasound to ablate the fibroids under MRI guidance. Effectiveness and outcomes are unconfirmed.
What are adhesions? Adhesions are fibrous strands/scar tissue, which can connect organs together. Organs in the peritoneal cavity (pelvic/abdominal space) normally slide freely against each other and adhesions can hinder this movement leading to complications such as pain, infertility and bowel obstruction. Adhesions are usually the result of injury to the peritoneum (lining of the abdomen and pelvis) and are part of the normal wound healing process. They do not always lead to problems but when they do, these can be widespread and severe.
What are the causes of adhesions? Surgery : there is an increased risk of adhesions after abdominal and pelvic surgery. Some types of surgery carry a higher risk of resulting in the development of adhesions. This includes ovarian, endometriosis, tubal surgery ?ectopic pregnancy, myomectomy (removal of fibroids) and adhesiolysis (removal of adhesions). Stitches during surgery can result in adhesions. Inflammation. The following can cause inflammation: • Inflammation - pelvic inflammatory disease, inflammatory bowel diseases (Crohn's disease, ulcerative colitis) appendicitis, especially if the appendix ruptures • Endometriosis • Infection: any type of infection can lead to adhesions if it is not treated quickly and effectively e.g. pelvic inflammatory disease, abscess, gastroenteritis Treatment:
Laparoscopic division of adhesions ( adhesiolysis) appear to reduce new adhesion formation. Research is currently ongoing in this area.