​ABNORMAL MENSTRUAL BLEEDING

 

Most women have, at least, a rough idea of when to expect their monthly visitors – the menses. But some are not so lucky. The visitor can just decide to barge in at any time. Irregular menses can be very embarrassing, frustrating and distressing. 
I have discussed normal menstrual cycle on this blog before, read it here… http://wp.me/p72X3S-1U

Let’s look at some of the definitions of abnormal menses. 
*Menorrhagia – heavy menstrual flow, which can be described subjectively as the need to change pads more frequently than before. 
*Metrorrhagia – prolonged menses lasting for more than 9 days. 
*Menometrorrhagia – combination of heavy and prolonged menses. 
*Hypermenorrhea – cycle length shorter than 24 days. 
*Hypomenorrhea – cycle length greater than 38 days. 
*Amenorrhoea – absence of menses for 3 or more consecutive months. 
*Inter-menstrual bleeding – bleeding or spotting in between the menstrual cycles. 
*Post-coital bleeding – bleeding or spotting after sexual intercourse. 
*Post menopausal bleeding – bleeding or spotting after menopause (after at least one year of confirmed menopause) 
*Irregular menstrual cycle – more than 7-9 days of disparity in lengths of cycles. 
What are the causes of irregular menses? 

Irregular menses are commoner in pubertal girls (11-14years) and older women who are approaching menopause. Other than these, irregular or abnormal menses can be due to any of the following – 
*Psychological stress, physical exertion, or sudden change in diet, environment, etc. 

*Problems with ovulation 

*Uterine fibroids

*Adenomyosis (a condition in which the uterine lining – endometrium – grows into the wall of the uterus) 

*Use of contraceptive pills and devices 

*Miscarriage 

*Ectopic pregnancy 

*Bleeding disorders

*Hormonal imbalance 

*Infections of the genital tract including the uterus 

*Cancers of the genital tract

*Co-morbid medical conditions such as diabetes, obesity, etc. 

*Some drugs, alcohol, tobacco smoking, etc. 
Management of abnormal menstrual bleeding depends on the cause. You need to visit a doctor who will take a detailed history and carry out some tests to determine the cause. 
Some of the tests you have to do are:

*Pregnancy test

*Ultrasound scan

*Endometrial biopsy 

*Hysteroscopy

*CT scan or MRI, if indicated 

*Full blood workup

*Hormonal profile 
Of course, treatment depends on the cause or definitive diagnosis. This can be medical or surgical. Certain general measures can be used to restore normal menses; such as weight loss and stress management. 
In conclusion, menstrual disorders and irregularities are quite common. It is important to understand the mechanism of normal menses, so as to be able to detect any anomaly and seek professional advice for prompt investigation and treatment. 

ECTOPIC PREGNANCY

a rebellious embryo may decide to implant itself outside the uterus!

After the fertilization of the egg by a viable sperm, the resultant embryo travels from the fallopian tube down into the cavity of the uterus. Implantation occurs when the embryo is attached to the uterine wall and continues to develop until full term gestation.

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However, for reasons that are not fully understood, a rebellious embryo may decide to implant itself outside the uterus!

Ectopic Pregnancies (EP) account for about 11:1000 pregnancies. More than 80% of such rebels implant in the fallopian tube, hence the name “Tubal Pregnancy”, often used interchangeably with EP.

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Other recognized locations of EP are the abdominal cavity, ovaries, cervix and cesarean section scar.

Because of the limited space for growth within the tube or other ectopic sites, rupture and severe internal bleeding could occur starting from 6-8weeks. Ruptured EP is a life-threatening condition and one of the major causes of maternal mortality.

What are the risk factors for EP?

  • Previous history of EP
  • Previous history of infertility and its treatment (assisted reproductive techniques)
  • Pelvic inflammatory disease (PID)
  • Intrauterine contraceptive device use at the time of conception
  • Endometriosis (presence of the uterine lining outside of the uterus)
  • Pelvic or tubal surgery
  • Smoking

The only way to ensure prompt diagnosis and treatment of EP is to have a high index of suspicion by recognizing the telltale signs.

 

The symptoms are variable and non-specific but there is a classical triad reported by many patients:

  1. Missed period (6-8weeks)
  2. Lower abdominal pain
  3. Mild vaginal bleeding or brownish discharge. 

 Other symptoms include:Shoulder tip pain (sign of internal bleeding-ruptured EP),  Sudden collapse (due to severe blood loss)

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    A diagnosis is usually confirmed by identification via ultrasound scan, supported by the level of an early pregnancy hormone known as Human Chorionic Gonadotropin B (BHCG). The modality of treatment depends on the clinical status.

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    *Surgical management – in ruptured EP, with acute severe blood loss, emergency surgical intervention must be done, together with blood transfusion to save the patient. 

    *Medical management – using methotrexate, in clinically stable patients who are compliant 

    *Expectant/Conservative management – in small sized EP and falling BHCG where the body is expected to get rid of the “rebel” by itself. This is reserved for a select few cases.

    Below is a summary of events in a woman with ectopic pregnancy and how the doctor chooses how best to help her.

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    ABORTIONS

    Abortion is defined as the termination of pregnancy before the age of viability (varies from country to country; 20 weeks in the US, 28weeks in Nigeria) or loss of a foetus weighing 500 grams or less. Abortion can be spontaneous or induced. Some gynecologists often prefer to use the word “miscarriage” for a spontaneous abortion. 

    It is estimated that up to 50% of all confirmed and unconfirmed human pregnancies will result in an abortion. However, by the 8th week of a viable gestation, the chances of a spontaneous abortion occurring drops to only 2-3%.

    Bleeding from the vagina is the commonest symptom of abortion. 30% of pregnant women experience some form of bleeding in the first trimester. About 50% of them will end up with a spontaneous miscarriage. Therefore, it is important to understand that, apart from impending abortion, bleeding during pregnancy could be due to other causes such as:
    *lower genital tract infections 

    *unprovoked or post-coital bleeding due to increased friability of the cervix

    *ectopic pregnancy (implantation of the embryo in any location outside the uterus) 

    *implantation bleeding

    What are the causes of miscarriage? 
    *Genetic causes – foetal genetic anomalies account for 70% of 1st trimester miscarriages 

    *Uterine causes – abnormal anatomy, growths or adhesions

    *Cervical causes – incompetent cervix

    *Infections of the genital tract and other systemic infections 

    *Endocrine causes – such as diabetes

    *Immunologic causes – such as antiphospholipid syndrome 

    *Toxins – such as alcohol, caffeine, high energy radiations, some drugs, etc

    What are the symptoms of abortion? 
    *Vaginal bleeding – from mild spotting to heavy bleeding, can be life-threatening if not treated promptly. 

    *Lower abdominal pain – can be mild to moderate to severe, sometimes no pain 

    *Passage of fetal tissues – clotted blood, fleshy materials, (take note of “vesicles” in case of molar pregnancy) 

    *Gush of fluid from the vagina – ie. amniotic fluid, in second trimester miscarriages 

    *Reduced or NO fetal movement – if the fetal movement has been perceived earlier 

    *Cessation of the usual early pregnancy symptoms 

    *Fever, malaise, vomiting etc – in septic abortion

    Clinical investigations

    -Full history and thorough examination 

    -Complete blood count

    -Blood group – especially Rhesus

    -BHCG levels – to rule out ectopic pregnancy 

    -Pelvic ultrasound 

    -Other investigations to determine the cause, especially in recurrent (>/= 3) pregnancy losses 

    Types of Abortion and their management. 
    *COMPLETE ABORTION – spontaneous expulsion of the foetus and placenta, bleeding stopped and cervix closed. No further management is required except ultrasound to confirm completeness.

    *INCOMPLETE ABORTION – passage of some fetal tissues but not all, cervix is open and bleeding continues. Management – group and prepare blood, IV fluids, medical or surgical evacuation of the remaining uterine contents, +/- blood replacement 

    *THREATENED ABORTION – bleeding but closed cervix. Management – rest and avoid intercourse 

    *INEVITABLE ABORTION – bleeding/rupture of membranes with cervical dilatation but no expulsion of foetus or placenta. Management – expectant, medical or surgical

    *MISSED ABORTION – foetal demise without expulsion, +/- bleeding, cervix closed. Management – medical or surgical. 

    *SEPTIC ABORTION – any abortion associated with uterine infection. Management – IV fluids, antibiotics, followed by surgical evacuation. 


    What are the complications of unsafe abortion or uterine evacuation? 
    If the evacuation is handled by a qualified personnel, using aseptic techniques, the complications are infinitesimally low. 

    Short term complications of unsafe abortion include: 

    *severe blood loss –  which can require blood transfusion and may lead to death if not treated promptly. 

    *infection – septic abortion 

    *uterine perforation 

    *damage to adjacent internal organs such as the bladder and bowels 

    Long term complications include:

    *uterine adhesions

    *menstrual dysfunction 

    *infertility

    IN CONCLUSION 

    -Pregnancy losses more than 3 consecutive times should be thoroughly investigated. A cause can be identified in 50-60% of cases and measures can be taken to prevent subsequent losses. 

    -Patients should be reassured that conception can be achieved within one cycle after complete abortion. The chances of a live birth after 2 or more consecutive miscarriages is up to 50 – 70%

    -A miscarriage can be physically and mentally traumatic. Women should be supported and reassured throughout this trying period.

    WHEN CANCER ATTACKS THE OVARIES

    The ovaries consist of different cell types, performing different functions. Any of these cells can develop into cancer

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    Ovarian cancer is the leading cause of death from gynecological cancers in the UK and USA. It is the 5th most common cause of cancer deaths in women (after lung, breast, colorectal and pancreatic cancers). Up to 20,000 new cases are diagnosed yearly in the US. The peak incidence is in women aged 75 – 84 years, but it can occur in younger women, and even (rarely) in prepubescent girls too.

     

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    CLASSIFICATION 

    The ovaries consist of different cell types, performing different functions. Any of these cells can develop into cancer, but 90% arise from the epithelial (outermost) cells. Ovarian cancers are classified based on the cluster of cells they originate from:

    • Epithelial
    • Sex cord-stromal
    • Germ cells

    ovarian-cancer-tumor-types

    Different subclasses have been described and each has similar features but different growth behavior and response to treatment.

    RISK FACTORS

    Like most cancers, direct causal factors are largely unknown, but various risk factors have been identified:

    • Nulliparity (no previous viable pregnancy)
    • Early menarche (age at onset of menstruation <11 years)
    • Late menopause (age at cessation of menstruation >52 years)
    • Family history of ovarian, breast or colorectal (bowel) cancers
    • Family history of genetic mutations ( BRCA1, BRCA2, and HNPCC)
    • Previous history of ovarian, breast, endometrial and colorectal cancers (treated)

     SCREENING FOR OVARIAN CANCER

    Not routinely done unless one has strong risk factors.

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    SIGNS AND SYMPTOMS

    Ovarian cancer is a great mimicker as it doesn’t show any specific sign until an advanced stage as been reached. Early symptoms are no different from those attributable to other common diseases. These are:

    • Abdominal pain
    • Abdominal distension and bloating
    • Loss of appetite
    • Constipation or diarrhea (or alternation of both)
    • Abnormal menses or vaginal bleeding

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    Late Symptoms include;

     

    • Abdominal/pelvic mass – detected by palpation and confirmed by radiological tests
    • Significant weight loss
    • Difficulty in passing urine
    • Significant abdominal distension (ascites or solid mass)
    • Generalized body swelling (edema or anasarca)
    • Signs of spread to distant organs – uterus and tubes, urinary tract, bowel, stomach, lymph nodes, etc.

     

    INVESTIGATIONS

    After taking a full history and physical examination, specific tests must be done to confirm the diagnosis, determine the extent of the disease and work up for definitive treatment.

    • Full blood count
    • Kidney function test
    • Liver function test
    • Tumor markers – CA125, CEA, CA19.9, etc.
    • Imaging: ultrasound, CT scan, MRI, chest x-ray, etc

     

    MANAGEMENT 

    1. SURGERY: This is both diagnostic and therapeutic. In early stages, the ovaries, uterus, tubes and adjacent lymph nodes will be removed at once. In advanced stages, initial surgery is done to “stage” cancer (to know what stage it is). Subsequent operations may be needed depending on the result of the first surgery and response or recurrence.
    2. CHEMOTHERAPY: The different combination of anti-cancer drugs are available depending on the cell types involved. The platinum-based therapy is given in up to 6 cycles every 3 weeks. Side effects of the drugs include severe vomiting, hair loss, kidney damage, diarrhea etc. These can also be managed and ameliorated.
    3. NOVEL AGENTS: New drugs are being investigated through clinical trials. These include antibodies against cancer-promoting factors in the body (VEGF, EGFR and TKI’s)
    4. SUPPORTIVE TREATMENT: These are palliative measures put in place to alleviate the excruciating pain and suffering associated with advanced ovarian cancer. Such as drainage of ascites, painkillers (strong opioids usually, morphine), emotional support, hospice care, etc.

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    FOLLOW UP IS OFTEN CONTINUED LIFELONG.

    5-year survival rate ranges from 90% to less than 20% depending on the stage of cancer before treatment is commenced.
    PREVENTION 

    It is said that the only way to not have cancer is not to be born. Ovarian cancer can not be predicted 100% but individuals with strong risk factors can be followed closely so as to detect the disease early. They can also opt for prophylactic oophorectomy (removal of the ovaries) after completing their reproductive career (cf. Angelina Jolie). For younger women, eggs can be harvested, frozen and used for IVF when they’re ready to get pregnant later.

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    General healthy lifestyle helps to prevent cancer among other things – healthy diet, regular exercise, quitting alcohol and smoking, etc.

    ​PELVIC INFLAMMATORY DISEASE AND ITS SEQUELAE

    The female genital system consists of the lower and upper genital tracts. Anatomically, the lower tract consists of the vulva, vagina and cervix while the upper part consists of the uterus, fallopian tubes, ovaries and the supporting tissues. Pelvic inflammatory disease (PID) is the infection of the upper genital tract, plus or minus the ovaries. 

    PID is often referred to as an ascending infection because the upper tract is relatively free from microorganisms compared to the lower tract which contains several harmless bacteria called “the normal flora”. There is a barrier at the level of the cervix. If this barrier is breached for any reason, the bacteria would ascend to the upper tract, causing PID. 

    Most PIDs are sexually transmitted, chiefly due to Neisseria gonorrhoea and Chlamydia trachomatis. Infection can also occur following instrumentation or surgical procedures whereby the cervix and uterus are accessed from below (eg. D&C, cervical/endometrial biopsy, hysteroscopy, intrauterine contraceptive device insertion, etc.) 


    What are the common signs and symptoms of PID? 
    *Lower abdominal/pelvic pain – usually starting after the menstrual period. 

    *Low back pain 

    *Fever

    *Nausea and vomiting 

    *Abnormal vaginal discharge – can be absent 

    *Loss of appetite 

    *Dysmenorrhoea (menstrual pain) 

    *Dyspareunia (painful sexual intercourse) 

    ***Note that PID can be totally asymptomatic and the first sign could be an incidental finding of a complication in a chronic case. 
    ***Other diseases that mimic PID must be ruled out. These include acute appendicitis, acute gastritis, urinary tract infections and problems of early pregnancy. Of course, pregnancy must be excluded as most patients are sexually active. 

    As noted above, most cases of PID go silently without symptoms. Some could resolve spontaneously and others progress chronically to complications. Once you notice any of the symptoms, it is important to see your doctor immediately. The doctor would take a detailed history, examine you and request that you do some tests. Some of the tests you should do include:

    *high vaginal swab – for microscopy, culture and other advanced (DNA-based) tests

    *full blood count – to check for elevated white cell count 

    *pelvic ultrasound – to detect possible tubo-ovarian abscess (collection of pus around the ovaries) 

    *renal and liver function tests – in complicated cases

    *laparoscopy – the gold standard for diagnosis, but not always necessary 

    *other tests to rule out differential diagnosis eg. Urine analysis and culture 


    What are the long-term complications of untreated or poorly treated PID? 
    *Infertility – due to adhesions in the tubes and ovaries (20% following one episode of PID, increasing with recurrent episodes) 

    *Chronic pelvic pain

    *Increased risk of ectopic pregnancy (implantation of embryo outside the uterus, mainly due to adhesions) 

    *Transmission to sexual partner

    *Septicaemia, septic shock and possibly, death. 


    Treatment

    Antibiotics should be started as soon as diagnosis is established. Usually, a combination regimen is used to cover a wide range of bacteria. Specific antibiotics must be used for specific bacteria isolated from the lab tests. Intravenous forms are preferred in severe cases, but can be switched to oral after 24-48hours. It is important to trace all recent sexual partners and let them get treated. Other STDs (such as HIV, Hepatitis B, etc) should also be tested for and managed as appropriate. 


    How can PID be prevented? 
    *General screening of “at risk” individuals, such as sexually active young women, those with multiple sexual partners, pregnant women, HIV positive persons, etc. 

    *Promotion of abstinence from indiscriminate sexual activities 

    *Use of condom

    *Mutual faithfulness between sexual partners 

    *Prompt treatment of acute disease to prevent chronic disease and it’s complications.

    ​WEIGHT MANAGEMENT BEFORE, DURING AND AFTER PREGNANCY

    A lot of women keep wondering if it is possible to control their weight during pregnancy and lose weight after childbirth. The answer is YES, it is possible. Before we proceed, let’s talk about the Body Mass Index (BMI). Your BMI is a measure of the appropriate weight for your height. You can calculate this by dividing your weight(in kg) by the square of your height(in meters). It is expressed as kg/m2 . 

    Optimum BMI for women is defined as 18.5 to 24.9 kg/m2 . As a result of the developing fetus/placenta, expanding uterus, increasing blood volume and amniotic fluid, weight gain is inevitable. However, your rate and target of weight gain depends on your pre-pregnancy BMI. Therefore, a slim woman needs to gain more while an obese woman gains less, but strict weight loss should be postponed until after delivery. 

    The best approach to maintaining healthy weight throughout pregnancy and beyond is to start BEFORE pregnancy. If you get pregnant with an healthy weight, chances are high that you will maintain a steady weight gain and then, lose all the weight thereafter. Overweight and obese women with increase weight gain, are more likely to have adverse pregnancy outcomes – gestational diabetes and hypertension, big babies and difficult delivery. Underweight women also stand a high chance of developing complications like miscarriages and small-for-age babies. 

    Women can achieve and maintain a healthy weight by:

    *Eating simple starchy foods and whole grains, such as brown rice, whole wheat bread, potatoes, yam and pasta

    *Eating fibre-rich diet such as fruits and vegetables, oats, beans, peas and lentils. 

    *Eating at least 5 portions of fruits and vegetables as daily snacks, instead of sweets and pastry junks. 

    *Minimising high calorie foods (like cakes and fizzy drinks) and choosing low-fat foods instead. 

    *Eating breakfast because when you skip breakfast, you’re more likely to overeat during the rest of the day. 

    *Eating small portions of meals and snacks. Small portions every 3 hours is more preferred to 3 binges 3 times daily. 

    *Exercising daily – walking, swimming and gardening, taking the stairs instead of the elevator, etc. Working women should take short walks every now and then, especially at lunchtime. 

    *Minimising sedentary activities such as watching television, using the computer and playing video games. 

    *Attending antenatal clinics regularly and keeping track of your weight at each visit – you can also buy a bathroom weighing scale to check at home. 

    *Attending post natal clinic after delivery and enrolling in weight loss programmes designed for new mums. 

    *Breastfeeding your baby exclusively, as this helps you to lose the baby weight quickly (among other benefits)

    *Liaising with a dietician to help calculate your calorie needs, especially if you’re diabetic. 

    Furthermore, we need to dispell common myths concerning nutrition and weight in pregnancy. There is no such thing as “eating for two”. You eat when you feel hungry and whatever you feel like eating (of course, with the exception of the unhealthy eating habits highlighted above). Conversely, you don’t have to starve yourself for the fear of gaining too much weight or having a big baby. If you’re ever in doubt, ask your midwife or obstetrician. 

    Reference: National Institute for Health and Care Guidance, UK (PH27, July 2010) 

    ​LADIES AND HEELS

    As a petite woman, there are times when I try to wear stiletto, just to give me that extra confidence for the occasion. But I always have a plan B to avoid a sprained ankle (carrying extra flat slippers). I envy ladies who go all day in high heels without batting an eyelid, my guess is that they are just suffering and smiling! 

    On a more serious note, frequent wearing of heels isn’t good for your lower limbs and back. When The Almighty created the feet, He made them flat and wide to serve as a comfortable shock absorber for the entire body weight. When you wear high heels, you put too much stress on your heel bones and toes. In order to maintain your balance, the stress is shifted upwards to your calf muscles. With time, the calf becomes more muscular and the veins around it become more prominent (and unsightly). This also promotes the emergence of varicose veins over time. 

    By extension, the knees, hips and lower back adjust spontaneously, to give you that staccato gait as you catwalk. The result is pain radiating from the toes up to the lumbar spine. There is accelerated ageing of the joints and nerves, not to mention skin bruises and calluses on the feet. Of course, heels are “NO NO” when you’re heavily pregnant. 

    Heels can make you look classy, but the long term effects outweigh the transient feelgood experience. You can look gorgeous in flats without getting a sprained ankle!