What is Endometriosis?

Endometriosis is a common condition that requires a bit of understanding. Normally there is a uterine lining that is made of tissue which is shed off every month cyclically. When this uterine [endometrial tissue]is present outside the uterus ,in the abdomen, pelvis, sometimes even in the chest , this is called Endometriosis.

A few sites where endometriosis may develop are

• The outside and back of the uterus
• In ligaments like uterosacral ligaments which support the uterus
• Ovaries
• Fallopian tubes
• Peritoneum(the smooth lining of the abdomen and pelvis)
• Rectum
• Urinary bladder and ureters
• Diaphragm
• Some scars like those of Caesarean deliveries

So what happens due to these endometriotic implants?

During the menstrual periods, this tissue which is outside the uterus, also thickens and bleeds. However since it can’t escape from the abdomen or pelvis, it becomes trapped. This blood causes ovarian cysts to develop and tissue around it also liberates some inflammatory chemicals that cause irritation, leading to scar tissue and adhesions-fibrous bands that cause pelvic tissues and organs to stick to each other. This is a simplified version to describe the effects of endometriosis.

Who is liable to get endometriosis?

Most commonly endometriosis occurs in women in their reproductive years (25-45 years) but it can also happen in adolescents. People in the menopausal years may find relief but it may still cause some discomfort and pain

Are there any risk factors for endometriosis ?

Yes

This condition may be genetic and may run in families. It is also common if you have onset of periods early ,before the age of 11 years. More frequent periods, longer days of bleeding and defects in the structure of the uterus may make one more liable to get this condition. Never giving birth and a late menopause are also risk factors.

What are the symptoms that point to endometriosis?

Some people may have endometriosis and not have any symptoms. The severity of endometriosis is not related to symptoms though. You may have mild disease and severe symptoms or even the reverse.

Pain or dysmenorrhea during periods is the commonest problem. Pain may be in the lower abdomen, back and pelvis; related or unrelated to periods and fairly constant.

Feeling tired all the time is another symptom.

Painful intercourse

Spotting between periods or heavy menstrual bleeding

Infertility

Painful bowel movements or uncommonly cyclical bleeding during passing urine or stool at the time of menstrual periods

Painful nodules at a surgical scar site that become larger and more painful at the time of menstrual  cycles

Breathlessness, chest pain, blood in cough during menstrual periods are also rare symptoms of chest or diaphragmatic endometriosis

How do doctors diagnose endometriosis?

Sometimes endometriosis may only need a good history and a high index of suspicion to be diagnosed. A pelvic or rectal examination is done. The other investigations are ultrasounds -preferably Transvaginal  or transrectal in young adolescent girls. MRI of the pelvis is also an important diagnostic tool. The gold standard of investigation is laparoscopy which may sometimes be done for other reasons like infertility. Endometriotic deposits may be seen and biopsies from these taken to prove  the disease. However not all biopsies may yield positive results. A high index of suspicion on the basis of history, examination, imaging tests and laparoscopy clinches the diagnosis.

What treatment options are available and who need treatment?

The treatment is based on

• Age of the patient
• Severity of symptoms
• Fertility issues
• Severity of the disease

Endometriosis is a very debilitating disease, progressive , and may impact the quality of life due to the pain , dysmenorrhea, painful sex and infertility it causes. It is also a recurrent disease and may come back even after surgical treatment and prolonged medical treatment.

Treatment may be medical or surgical or a combination of the two. Medical treatment may be NSAID pain killers, hormones- oral, injectable or hormone containing IUDS or implants.

Surgical options include laparoscopy or hysterectomy.

What happens due to untreated endometriosis?

There may be formation of cysts and adhesions in the pelvis. The pelvic organs like the bowel, bladder, ureters , tubes and ovaries may get stuck to the uterus, obliterating and distorting normal anatomy , often posing a risk even of injury during surgical procedures. Hence highly experienced surgeons are needed to perform surgeries related to endometriosis.

Surgery too should be optimal and not done again and again. Symptoms of endometriosis become better during pregnancy but contrary to popular belief pregnancy does not put an end to this progressive  malady. Post menopausal women may get respite but there may still be a mild discomfort.

Is Endometriosis linked to malignancy?

Yes, there is a small risk of ovarian cancer but if regular follow up is done , there is no need to panic .

In conclusion , endometriosis is a debilitating illness -both physically and mentally , progressive, multi factorial, involves many organs , sometimes a diagnostic dilemma too. But being informed and aware, discussing treatment options with your doctor and getting the right treatment at the right time, based on your needs and symptoms goes a long way in increasing the quality of life  and managing your symptoms.

This is an unusual topic as the incidence of vulvovaginal trauma is not very high .

What is the vulva ?

The external female genitalia comprising the mons pubis ( the mound formed by pelvic bones) the labia majora and labia minora ( the lips ) , clitoris , vaginal and urethral opening comprise the vulva . There’s a slight variation in the labia of children and adults . In little girls the fat pads of the labia majora are not very well developed , so children are more prone to vaginal trauma due to reasons that I’ll elucidate a bit later .

What are the causes of vulvovaginal trauma ?

Injuries to the vulva or vagina or both could occur due to several reasons :

• The commonest reason is childbirth as the fetal head negotiates the birth canal and vaginal opening
• Injuries during childbirth could also occur due to operative delivery such as the use of obstetric forceps or a vaccum delivery . The fetal shoulders getting stuck at the vaginal opening due to a large baby , called shoulder dystocia is also a reason for these injuries .
• Penetrative injuries due to forceful consensual or non consensual sex such as sexual abuse may also lead to such trauma . Even the use of penetrative objects inside the vagina during sex or sexual molestation may lead to vaginal and vulval tears or hematomas.
• Straddle injuries due to falling on the crossbar of a bike leading to a blunt force or complex injuries due to blunt trauma
• Gunshot or knife wounds
• Children may also insert objects inside the vagina causing injuries that they may sometimes be shy to report .

What are the types of injuries ?

These injuries depend upon the cause , the intensity of force / fall and the age of the patient . They are more likely to be severe in the very young and the very aged due to thinning and dryness of the vagina .

Both the vagina and the vulva are richly supplied by blood vessels so bleeding may be fairly intense , sometimes even life threatening .

They may be superficial tears or deep tears involving the urethra and anal or rectal region too or even go deep into the pelvic organs and even pelvic bones for instance during vehicular accidents .

Sometimes vulval and vaginal trauma presents with hematomas or blood collection.

How are these injuries diagnosed and treated ?

A careful history and examination of the genitalia , sometimes with anesthesia is needed to see the extent of the injury and the type .

If the cuts / injuries / tears are very superficial and have stopped bleeding nothing more needs to be done other than local Sitz baths with or without painkillers and antibiotics . If there is severe bleeding ,it may need to be surgically repaired . Hematomas may also be evacuated surgically .

So if the cuts or tears are very deep , many in number , bleeding incessantly or not healing or seem to be getting infected ( fever , chills , pus from the site ) medical attention is needed . Also if there is sexual abuse it should be reported and addressed both medically and medico-legally . Social workers and psychologists may also be helpful to holistically treat the mental trauma that comes along with the physical trauma .

There is an increased number of twin pregnancies and higher order births owing to more cases of pregnancies due to artificial reproductive technology (ART) or IVF. Even liberal use of ovulation inducing medicines leads to a greater incidence of twin and higher order pregnancies. There are specific challenges to twin pregnancies; one of the commonest being preterm births.

How common are preterm births in twin pregnancies?

About 50 % of twin pregnancies end in preterm births before 36 weeks (a month before the 40 weeks of singleton pregnancies). Some studies have shown that preterm deliveries at <37 weeks are 5.7 times more and at <32 weeks 7.1 times more in twin pregnancies compared to singleton pregnancies . Twin gestations of 36 weeks are equivalent to 40 weeks singleton pregnancies. The reasons for preterm deliveries in twin pregnancies are many.
The first could be due to early delivery which is needed medically due to associated complications of twin pregnancies called Iatrogenic preterm deliveries; the other is due to overdistension of the uterus which is part and parcel of bearing two babies , sometimes with a large placenta and excessive amniotic fluid around the babies . This could lead to spontaneous preterm labour or due to PROM (preterm rupture of membranes)

Let’s delve into both these reasons

One of the common problems in twin gestation is Preeclampsia.
Preeclampsia is defined as high blood pressure after 20 weeks of pregnancy accompanied by swelling of the body and protein in the urine. Preeclampsia causes severe risks to the pregnant lady. These include throwing fits (eclampsia) , clots in the brain , liver derangements , bleeding disorders due to low platelets and breathing disorders due to lung issues .

There can also be premature separation of the placenta from the uterus causing ominous bleeding both concealed in the uterus and revealed. Even intrauterine deaths of babies are a known complication due to this condition called abruption placentae. This preeclampsia may warrant preterm delivery due to the above mentioned complications.

Placental problems

Twin pregnancies may be associated with a single placenta or two separate placentas depending on the type of twin gestation. The placenta is attached to the uterine wall and supplies oxygen and nutrients to the babies. A large placenta may be low lying in the uterus (placenta previa) which can bleed at any time, sometimes prematurely, causing the need to do an urgent preterm delivery.
Abruption, as mentioned above, also leads to bleeding – internally inside the uterus or externally, warranting a preterm delivery to save the lives of the mother and babies. Another condition in single shared placentas with shared circulation between twins is called TTTS or Twin to twin transfusion syndrome which may sometimes require a preterm delivery if it compromises the babies.

Premature rupture of membranes (PROM)

Twin babies are enveloped in sacs of liquor called amniotic fluid. In twin gestation, due to overdistension of the uterus, there may be a preterm leaking of amniotic fluid due to breaking of this “ water bag”. This is far more common in twin gestation compared to singleton pregnancies. PROM can lead to infection and also precipitate preterm labour. This is one of the reasons why preterm deliveries are commoner in twin pregnancies.

Fetal growth restriction

Preterm babies are generally smaller than singleton ones. These babies are small or do not fulfill their full potential for growth inside the uterus due to numerous factors. Some twins may be selectively fetal growth restricted which means one baby is significantly smaller than the other due to shared unequal circulation etc. If these babies do not grow adequately in the womb, early delivery may be needed.
Hence, whatever be the reason – medically induced or spontaneous, preterm deliveries are more common in twins and come with their own set of problems post birth. Whenever diagnosed with twin gestation it is a good idea to discuss all the issues which come with the little ones Remember: “Two babies twice the fun, Though many times, preterm ones.”

An unwanted pregnancy – alarm bells start sounding ! Panic buttons set and there is a need to immediately terminate the pregnancy .

Is there a right way to do this ?

The answer is yes .
Instead of hurrying to the nearest chemist shop and buying the kit over the counter , often with no instructions or half baked instructions of the pharmacist , which often leads to disastrous consequences it’s best to meet your gynaecologist . And why is that ?

Let’s go over the correct way of a medical abortion using pills .

The pregnancy must first be confirmed , initially with a urine pregnancy test or a serum B HCG test and then with an ultrasound . The ultrasound confirms an early pregnancy as also it’s location . Sometimes the pregnancy may be lodged in the tubes , called an ectopic pregnancy and at other times a molar pregnancy may be diagnosed ( grape like growths which develop in the uterus instead of an embryo )

In both cases if the abortion kit is used without supervision there may be life threatening risks . Medical abortion kits are recommended for intrauterine pregnancies upto 8 weeks , not more as there are higher chances of failure and heavy bleeding due to the procedure . That’s the reason an early pregnancy inside the uterus must be confirmed on ultrasound .

Contraindications to use of medicine include asthma and severe respiratory disease , allergy to the medicine , adrenal disorders , long term corticosteroid use, porphyria, known blood thinning or anticoagulant therapy . This method is also undesirable for people who will not be able to understand or to follow instructions about use and risks and for those who can’t be in regular follow up with their gynaecologists or registered medical practitioners . So that’s a huge check list of people who are eligible or ineligible for the medical abortion kit .

Once you are eligible to use the medical abortion kit by a proper history , examination and ultrasound examination , you are counselled on how to take the medicine , the procedure , side effects and follow up . You are made to sign a consent form and asked to be in touch with your doctor in case there is the slightest problem during the course of this treatment which is somewhat long drawn and not always fool proof in terms of a complete abortion .

What to expect during the course of a medical abortion and what can go wrong ?

Once you are given the pills by specific protocols , you can expect to have severe cramping in the abdomen and heavy bleeding . This bleeding is initially heavier than a normal period and may be accompanied by fleshy pieces which are products of conception along with clots . This bleeding usually may become a little less in the following days but typically remains for 7-10 days or slightly longer . Other side effects of the medicine include headache , vomiting , diarrhoea , chills , fever , dizziness and lightheadedness .You are asked to get an ultrasound on day 10-14 of the procedure to see if the abortion is complete or if there are residual products of conception which may required to be removed by another medicine or a surgical aspiration or cleaning .

Now what can go wrong ?

There may be severe bleeding that is precipitated due to the abortion pills .

If you soak more than one maxi pad completely in one hour for 2 successive hours it implies you are bleeding heavily . Moreover bleeding slightly more than normal may also be relatively heavy for a patient with low haemoglobin levels or anaemia . This heavy bleeding may be life threatening as it leads to hemorrhagic shock and may require to be stopped by a surgical evacuation and even blood transfusion in around 0.1 % of medical abortions . Imagine if you are sitting at home while this happens ; the events are horrific .

In case you’ve taken the medicines without ruling out an ectopic pregnancy , that could rupture leading to severe internal bleeding , shock and collapse . And in case any eventuality like this happens , who will be held responsible ? Certainly not the chemist who sold and prescribed the medicine because according to the MTP act , an abortion can only be done by a qualified gynaecologist or an experienced registered medical practitioner .

However this does not mean you will be in hospital for the entire course of a medical abortion . Your doctor will prescribe the medicine and you will be at home under her / his care and supervision just in case anything goes wrong . Also remember , though rare , medical abortions may lead to infertility due to infections of the genital tract ; hence proper screening , evaluation and follow up is of vital importance .

Unwanted pregnancies are definitely bothersome but remember contraception and prevention is the key . However should they happen always remember to take medical abortion kits in the right way and under supervision , equipped with all the knowledge ( not with Google or your peers) and with all the choices available .
Medical abortion kits used at home without medical supervision can indeed be disastrous and sometimes life threatening so choose to be safe and sensible .

Talk to your doctor right away !

Over the past few years medical practice has changed a lot , and so has the online pursuit of it ! Symptoms , diagnoses , differential diagnoses , randomised control trials and studies are a click of a button away .

Dr Google is now a reliable reference source , often a first point contact for most patients even before they see us , the clinicians . Most people have already done their research and come up with a diagnosis . Dr Google certainly contains a lot of information , a lot of truth and some fiction too ! The gulf between truth and accuracy and fiction can be huge.
Most people come up with fears of cancer , ectopic pregnancies , miscarriages , perforated intestines due to IUCDs, strokes , heart disease and the like even for the simplest complaints that have nothing to do with these ( of course having Dr Google as a partner in this diagnosis ) There are many however who may have made a correct diagnosis with the plethora of medical information available online .

I’d say one thing – please be educated and aware of whatever ails you ; Google away ! But don’t let Google make your diagnosis . Don’t trouble and stress yourself over humongous ominous diagnoses made with your online friend . Those sleepless nights are just not worth it . Worse still , don’t sit tight over complaints you may have , having being assured by Google that all is well .

It has taken us years and years of study and research , experience and pursuit of medicine to earn our degrees. Let Google not take that away from us ; let it be an accompanying aid but not your only doctor ….

Talk to your doctor today !

POI is a condition where ovaries stop functioning before the age of 40 years ; ovulation stops and so does release of hormones – estrogen , progesterone and testosterone .

How do we diagnose POI?

Diagnosis is made by evaluating the frequency of periods ( over at least 4 months ) and by checking hormone levels ( FSH levels of more than 25IU/l at least in 2 blood samples 4 weeks apart and low estradiol levels ) It is seen in about 1 % of the population .

What are the causes of POI ?

Iatrogenic – which means those that are caused due to medical treatment like chemotherapy , radiotherapy or surgery involving removal of ovaries or a part of them for benign or malignant disease .

Non Iatrogenic –

• Genetic or chromosomal causes such as Turner’s syndrome or Fragile X syndrome . Your doctor will do a genetic testing whenever these genetic causes are suspected .
• Autoimmune diseases in which our bodies fighters the antibodies turn against our own bodies . These autoantibodies could destroy our own thyroid gland cells, adrenal gland cells or even ovarian tissue leading to POI . Your doctor will check you for some autoantibodies .

-Type 1 Diabetes

-Idiopathic – unexplained reasons leading to POI

Why is POI a big problem ?

POI if untreated leads to decreased life expectancy mainly due to cardiovascular disease owing to the deficiency of estrogen in our body .

What are the symptoms of POI?

• Amenorrhea or stopping of periods
• Oligomenorrhoea -Less frequent periods
• Hot flushes
• Irritability
• Depression
• Anxiety
• Night sweats
• Vaginal dryness
• Reduced sex drive
• Repeated UTI
• Tiredness
• Sleep disturbances
• Poor memory and concentration

How can we treat these symptoms ?

• Healthy lifestyle : regular exercise including weight bearing exercises to prevent osteoporosis or bone thinning , eating healthy and a balanced diet and stopping smoking and alcohol .
• Regular health checks including those for bone health and cardiovascular health . At least annual check ups are recommended .

What effects does POI produce on our bodies ?

• Infertility
• Reduced libido , vaginal dryness and pain during sexual intercourse.
• Increased chances of heart disease and strokes due to reduced estrogen in our bodies .
• Forgetfulness
• More chances of fractures due to reduced bone mineral density or osteoporosis .

What are the options for treating POI?

-Hormone Replacement Therapy – your doctor will take a complete history , examine you and do the relevant investigations before prescribing the same . Which HRT to use and whether oral medication or local therapy in the form of gels and patches will depend on what your doctor thinks is best for you and on your preferences . There’s no one size that fits all. There are numerous options available and every patient is different – hence the need to individualise each treatment .

• Local creams, pessaries , lubricants
• Vitamin D and Calcium supplements

Alternative therapy options like soy, black cohosh , evening primrose oil etc which may reduce symptoms in a small number of women .