Gynaecology Information

*Information brochures are not designed to replace information provided by your treating doctor or health care team. If you have any questions that you would like to ask, please speak to Dr Cattanach during your consultation or contact the clinic on 07 3844 9917 during office hours.

Below is a list of just some of the gynaecological conditions we treat in our rooms.

Colposcopy

Information coming soon...

Endometrial ablation

What is endometrial ablation?

Endometrial ablation means the removal of the endometrium, or the lining of the uterus. It is one way to treat heavy periods or abnormal menstrual bleeding. For some women, it can be an alternative to hysterectomy.

Endometrial ablation is not appropriate for all women with menstrual bleeding disturbances. For example, it is not suitable when there is any suspicion of cancer or where the uterus is enlarged or contains many fibroids. It is not suitable for women who may wish to become pregnant because in most cases, but not all, it results in infertility.

What is involved ?

The procedure involves removal of the endometrium using electrocautery, a roller ball, a cutting loop, or sometimes a laser. Usually a diagnostic hysteroscopy and/or curettage (D&C) is performed prior to endometrial ablation, to assess whether this procedure would be appropriate.

Frequently, medication is prescribed for four to six weeks prior to treatment, so that the uterine lining is very thin at the time of the procedure. Danazol and Provera are the most commonly used medications.

The procedure is usually performed under a general anaesthetic. The cervix (or neck of the womb) is dilated or stretched and the hysteroscope, which is a narrow telescope, is passed through the cervix. This may be connected to a video monitor. The endometrium or uterine lining can then be removed using electrical current (diathermy) or microwave energy. During the procedure, the uterus is continually flushed with fluid to keep the uterine cavity open and to rinse away blood. The procedure usually takes 30 to 60 minutes and sometimes a laparoscopy is performed at the same time, to check the outer surface of the uterus.

The woman can usually be discharged from hospital the same day.

What results might be expected?

About fifty per cent women who have this procedure have no further periods and about 45 per cent continue to have light periods. For approximately five per cent, troublesome periods will persist, and a further endometrial ablation or hysterectomy may be necessary.

What about complications?

While serious complications are rare, no surgery is without risk of complications, even including death. Because it is a comparatively new procedure, the long-term results are not yet known but it is likely that the overall risks and complications will be less than those for hysterectomy. Anaesthesia itself is never without risk and the risks are greater for women who smoke or who are significantly overweight.

During the procedure, bleeding is occasionally troublesome and on rare occasions a blood transfusion is necessary. Infection may occur, but is generally readily treated. It is possible for the wall of the uterus to be punctured by the instruments or by electrical current. If this happens, there may be damage to the bowel, which may require open surgery, and hysterectomy may also become necessary. Injury can occur to other intra-abdominal structures and require further emergency surgery. Because of the manner of flushing the uterus the body can absorb excess fluid. This may on rare occasions cause severe problems with blood chemistry. Some of these complications will depend on the nature of the particular problem and the exact technique used.

The advantages

Symptoms are cured without having to remove the uterus.

Compared with hysterectomy, the hospital stay and convalescence are short, a practical and economic advantage to most women.

Recovery

One to two weeks of vaginal bleeding may be expected, after which some discharge may persist for up to a month. It is normal to have some aches and cramps during the first week or so. Intercourse should be avoided for about two weeks or until bleeding has stopped, and strenuous activity should be avoided for one month. Some doctors prescribe hormone treatment to keep the uterine lining thin during the first month or so after the procedure.

Afterwards

The outcome of the surgery may not be clear for 12 months but, as indicated above, the majority of women have no periods or considerably lighter periods after the procedure. The uterine lining shrinks and the endometrium is replaced by a thin layer of scar tissue. The uterus and neck of the womb are still present so regular Pap smears should be continued.

The ovaries are untouched, so hormone function can be expected to continue until the normal time for the woman to experience menopausal symptoms. Apart from the loss of periods, this procedure will not affect the time at which hot flushes, mood changes and other menopausal symptoms would be expected to occur, nor should it have any effect on weight.

It should not be assumed that endometrial ablation will prevent pregnancy. Although pregnancy is extremely unlikely following the procedure, some have occurred. It is not known whether such pregnancies could be expected to have a normal outcome. The doctor should be consulted about contraceptive methods.

Follow up medical checks will be arranged by your doctor usually at about six weeks and thereafter as appropriate.

Endometriosis

What is endometriosis?

Endometriosis is a disease affecting about 5% of women and is defined as the presence of endometrial tissue (normally found only as the lining of the uterine cavity) in locations outside the uterus. Most commonly this is in areas around the uterus in the female pelvis especially the Pouch of Douglas, Broad Ligaments, Lateral pelvic wall, ovaries, tubes, bladder and uterine surface. Sometimes it involves the vagina, bowel and appendix and rarely is found in other sites around the body.

Symptoms

Symptoms vary from no symptoms at all to severe disabling pelvic pain worse mid-cycle and prior to and during the menses. Other symptoms include pain with intercourse (dyspareunia), abnormal uterine bleeding, pelvic mass and infertility. If the disease involves the bladder or bowel in some way then symptoms may arise involving these structures. Some patients with very little endometriosis have severe pain and others with severe disease causing extensive pelvic adhesions may have minimal discomfort.

Why does endometriosis occur?

There are many theories attempting to explain why endometriosis occurs including retrograde menstruation through the tubes, but hormonal and immunological factors seem to also play a part. Endometriosis commonly occurs in families (genetic). Anatomical factors seem to increase risk (e.g. cervical narrowing). The oral contraceptive pill, pregnancy and lactation reduce the risk.

How is it diagnosed?

Laparoscopy is the most usual method of confirming the presence of endometriosis. Clinically suspicion arises when a woman complains of pelvic pain symptoms and vaginal examination elicits tenderness, nodularity in the pelvis, poor mobility of organs or a pelvic mass might also be found. The diagnosis involves a surgeon seeing and preferably taking a biopsy. The gynaecological surgeon then assesses the extent of the endometriosis and grades it according to the extent site(s) and scarring formation as well as the presence of collections of ’chocolate: fluid cysts in the ovaries (endometriomas)’.

Treatment

Treatment frequently begins with laparoscopy. Following diagnosis and assessment the lesions, adhesions and endometriomas, if present, are removed. The disease is often widespread and microscopic, so treatment is likely to be incomplete in some women even when all visible lesions are removed.

Medical treatments may be considered if the disease was too extensive to treat at the ’diagnostic laparoscopy’ and it may be desirable to ’shrink’ and reduce the vascularity of the endometriosis prior to treatment surgery. Medical treatments have a mixed record of success but can hold the disease at bay.

Medical treatments include

  • Progestogens such as Duphaston and Provera
  • The oral contraceptive pill which can be taken continuously
  • The so called GnRH antagonists such as Synarel and Zoladex
  • Anti-oestrogens such as Danocrine and Gestrinone

It is our practice to supply detailed information brochures to patients with a potential diagnosis of endometriosis.

Links

PowerPoint Presentation Slide Show on Endometriosis

Fibroids

What are fibroids?

Leiomyomas and myomas are also names given to the benign ball like smooth muscle tumours which commonly grow in the uterus. They usually occur in multiples and most women have a few by the age of 40. They are usually asymptomatic but they are the most common reason for hysterectomy by the age of 50.

What causes fibroids?

The cause of fibroids was until recently unknown. They often occur in families so there is a genetic component to the cause. There appears to be a defect in the ’housekeeping’ gene for the enzyme fumarate hydratase. The tumours are oestrogen dependent and regress when oestrogen levels fall after menopause but may grow with hormone replacement therapy.

Symptoms

Fibroids may cause menorrhagia (heavy periods) especially when they grow inside the cavity of the womb or distort the cavity by growing in the wall. They may cause pressure symptoms especially when the size or number of fibroids cause the uterus to enlarge to the size of an orange or grapefruit (it is usually passionfruit size). This may manifest as a feeling of fullness in the pelvis and pressure on the bowel or bladder and may cause various symptoms related to the functions of these organs. Fibroids may cause significant pain and rarely, infertility. Complications from fibroids include torsion and infection, obstruction to urine flow through the ureters and acute degeneration.

Treatment

Treatment may not be necessary unless there are symptoms. Medications for shrinking fibroids are not on the PBS listing for this indication, because once treatment is finished the fibroids tend to grow back quietly. Hysterectomy and myomectomy and multiple myomectomies are the 'usual' treatments offered where symptoms warrant some form of treatment. Hysterectomy may be offered for those who have completed their family and laparoscopic or open myomectomy is sometimes appropriate for those who want to maintain their fertility. An exciting new treatment is radiological embrolisation which cuts the blood supply by putting small plastic beads into the branches of the uterine artery.

Useful web sites

Glossary

Laparoscopy

A procedure to view inside the pelvis and abdomen using a fine telescope-like instrument, usually inserted into the abdomen below the umbilicus.

Hysteroscopy

A procedure to view the inside of the uterus using a fine telescope-like instrument inserted through the cervix.

Curettage

A procedure which removes the lining of the uterus.

Laparoscopy

What is Laparoscopy?

Is a surgical technique where a long telescope is placed, via a keyhole incision at the umbilicus, into the abdomen in order to examine its contents. Other incisions are placed often to the left and right as well as central lower abdominal areas so that long handled instruments can also be placed into the abdomen in order to ’operate’ on a patient. The abdomen is ’inflated’ using carbon dioxide gas and the telescope is linked to video cameras so the surgeon, operating assistant and scrub nurse can work as a team without opening the abdomen with a large incision.

The advantages of laparoscopy

The technique has many advantages including shortening the stay in hospital, reducing pain and often giving a better view of the internal organs. Gynaecologists use laparoscopy to diagnose and treat endometriosis, pelvic adhesions, ovarian cysts and tumours, fibroids in some instances, pelvic floor prolapse and stress incontinence, infertility and to help perform hysterectomies. It is useful in assessing causes of pelvic pain and infertility as well as in carrying out sterilisation procedures, or for treating pregnancies inside the tube (ectopic pregnancy).

Is laparoscopy safe?

Laparoscopy, like all medical interventions, is not without risk. The operation involves entering the abdomen and organs such as the bowel, bladder, ureters (kidney tubes) and blood vessels are close to these sites. Gas can enter blood vessels if they are punctured and this can cause a life threatening complication.

Sometimes postoperatively the small incisions can become infected. Often there is some lower abdominal discomfort and shoulder pain from the presence of residual carbon dioxide gas inside the abdomen. It is our practice to supply detailed information brochures to patients who are contemplating this type of surgery.

Vaginal prolapse

What is vaginal prolapse?

The ’front’ wall of the vagina is related to the urethra and bladder and is the most common part of the vagina to ’sag’. The posterior wall of the vaginal is related to the rectum and is also a common site for prolapse. The uterus and cervix may travel down the vagina, in some cases, and even protrude through the vaginal opening.

Symptoms

Symptoms of prolapse include

  • a feeling of something coming down in the vagina
  • a palpable or visible lump protruding form the vulva
  • pelvic discomfort and back pain
  • sometimes difficulty emptying the bowel or bladder or incontinence of urine is experienced.

Assessment

Initial assessment involves a careful evaluation of symptoms and a pelvic examination to assess what parts of the vagina are prolapsing and which support structures are deficient.

Treatment

Treatment involves a multi-discipline approach with physiotherapy, pelvic floor exercises and if menopausal, local oestrogen treatment. Urodynamic testing may be required to assess causes of urinary incontinence and the type of surgery is then discussed and explained.

The most common surgical approach is via the vagina but some types of prolapse are best repaired via the laparoscope.

Dr Stephen Cattanach