Gynecological

ADENOMYOSIS

About

- A thickening of the uterus
- Occurs when endometrial tissues moves into the uterus’ outer muscular walls
- May result in an adenomyoma, which is a mass/growth inside the uterus

Potential Causes

- Unknown
- More common in women who have had multiple children

Symptoms

- Painful menstruation
- A uterus that is 2-3x its normal size
- Can be asymptomatic

Diagnosis

- A pelvic exam that reveals an enlarged, tender uterus
- Ultrasound/MRI imaging of the uterus can detect signs of it
- The only way to confirm a diagnosis is to examine the uterus after hysterectomy

Treatment

- Heat application: Baths, heating pads, hot water bottles
- Anti-inflammatory drugs (NSAIDs): Taking them 1-2 days before the start of your period and during your period can reduce menstrual blood flow and help relieve pain
- Hormone medications: Combined estrogen-progestin birth control pills, patches or vaginal rings might reduce heavy bleeding and pain
- Intrauterine Device (IUD): Can keep you from getting your period, which might provide some relief
- Hysterectomy: If your pain is severe and no other treatments have worked, your uterus can be removed

ENDOMETRIOSIS

About

- A disorder in which endometrium-like tissue is found outside the uterus
- Each month, the misplaced tissue responds to the hormonal changes of the menstrual cycle by building up and breaking down just as the endometrium does, resulting in small bleeding inside of the pelvis
  - Leads to inflammation, swelling and scarring of the normal tissue surrounding the endometriosis implants
- When the ovary is involved, blood can become embedded in the normal ovarian tissue, forming a “blood blister” surrounded by a fibrous cyst, called an endometrioma
- All women can get this condition, but those who are more susceptible to it include those who are:
  - Genetically predisposed
  - Giving birth after 30

Potential Causes

- The body’s inability to break down backflow (retrograde) menstruation
- Genetics
- Metaplasia (transformation of one differentiated cell type to another differentiated cell type)
- Circulatory/lymphatic distribution of endometriosis lesions
- Potential Cause of Infertility from Endometriosis
  - Scar tissue may impair the release of the egg from the ovary and subsequent pickup by the fallopian tube
  - Changes in the pelvic environment may potentially result in impaired implantation of the fertilized egg

Symptoms

- Very painful menstrual cramps that may be felt in the abdomen/lower back
- Pain with/following intercourse
- Occasional heavy menstrual periods/intermenstrual bleeding (bleeding between periods)
- Painful urination/bowel movements during menstrual periods
- Other gastrointestinal problems, such as diarrhea, constipation, bloating and/or nausea
- Difficulty getting pregnant
- The severity of pain is not necessarily related to the severity of the disease
  - Some women have mild endometriosis with severe pain and others have advanced endometriosis with little/no pain

Diagnosis

- Evaluation of medical history
- Pelvic exam
- Ultrasound
- CT/MRI scan
- Laparoscopic surgery performed in some cases to determine the location, extent and size of the endometrial growths
  - Tissue is biopsied to confirm diagnosis
- Stages:
  - Stage 1: Minimal
  - Stage 2: Moderate
  - Stage 3: Mild
  - Stage 4: Severe

*Stages are based on the location, amount, depth and size of the endometrial tissue and do not necessarily reflect the level of pain experienced, risk of infertility or symptoms present

- Specific criteria include
  - The extent of the spread of the tissue
  - The involvement of pelvic structures
  - The extent of pelvic adhesions
  - The blockage of the fallopian tubes

Treatment

- Pain relievers: Anti-inflammatory drugs (NSAIDs)
- Hormone therapy: Oral contraceptives to prevent ovulation, reduce menstrual flow and pain
- Progestin therapy: An intrauterine device (IUD) with levonorgestrel, contraceptive implant, contraceptive injection or progestin pill can stop menstrual periods and the growth of endometrial implants
- Gonadotropin-releasing hormone agonists and antagonists: Block the production of ovarian-stimulating hormones, lowering estrogen levels and creating an artificial menopause
  - Causes endometrial tissue to shrink
- Aromatase inhibitors: Medications that reduce the amount of estrogen in your body
  - Work in conjunction with progestin or combination hormonal contraceptive
- Fertility treatment: Stimulating your ovaries to make more eggs/in vitro fertilization
- Laparoscopy: To remove endometrial tissue for those in severe pain/trying to get pregnant
- Laparotomy: A more extensive surgery to remove as much of the displaced endometrium as possible without damaging healthy tissue
- *A combination of therapies can be used such as conservative surgery along with hormone therapy
- Helpful ways to ease the pain of endometriosis include the following:
  - Rest
  - Relaxation through restorative yoga and meditation
  - Heat application via baths, heating pads and hot water bottles
  - Staying regular
  - Exercise
- Alternative treatments used in conjunction with other medical and surgical therapies can be beneficial and include the following:
  - Traditional Chinese medicine
  - Diet modifications
  - Homeopathy
  - Immunotherapy

LICHEN SCLEROSUS (LS)

About

- Skin condition that affects the skin in the genital and anal area
- Can also appear on the upper body, breasts and upper arms
- Can cause whitening of the genital skin and/or thickened white patches
- The skin may appear wrinkled and thin, although LS causes skin thickening underneath the top layer of skin

Potential Causes

- Cause is unknown, but researchers speculate that one or more of the following may cause/contribute to the condition:
  - - Genetics
    - Hormones
    - Irritants
    - Trauma
- Not due to an infection
- Not contagious and cannot be spread through any contact, including sexual intercourse

Signs & Symptoms

- Signs
  - Whitening of the vulvar skin
  - Thickened patches of white skin
  - Whitened skin that may appear wrinkled, waxy, thickened or thin
  - Changes to the anatomy of the vulva such as loss of the labia minora, fusing of the labia minora to the labia majora and fusing of the clitoral hood to the glans clitoris
  - Scarring at the entrance of the vagina (the introitus)
  - Partial or complete fusing over the urethra
  - Bruising (may appear purple-reddish, depending on the colour of your skin
  - Fissures, tears, blood blisters and lesions

- Symptoms
  - Itching (can be mild and sporadic to constant and severe)
  - Burning
  - Pain with sexual intercourse
  - Tearing during sexual intercourse
  - Difficulty with bowel movements (if LS affects the perianal area)
  - Stinging pain from fissures and cuts
  - Generalized vulvar discomfort

Diagnosis

- A dermatologist/gynecologist can visually confirm a diagnosis from the typical appearance of the condition
- If there is any doubt, a small skin biopsy may be taken and examined under a microscope to confirm

Treatment

- Ointment: Clobetasol propionate 0.05% to stop inflammation and soften the affected skin
- Moisturizers: To help soften and protect the skin
- Cleansing: Gently wash the affected area daily and pat dry
  - Avoid harsh soaps and bathing too much
- Ice/cool compress application/sitz baths/oatmeal solutions: To ease burning and itching
- Antihistamine: To help control the itching
- Regular genital skin checks
  - Chances of vulvar cancer increase if you have LS
  - With good control of the signs and symptoms, this risk is reduced further

PELVIC ORGAN PROLAPSE

About

- Downward descent of female pelvic organs including the bladder, uterus and the small/large bowel, resulting in protrusion of the vagina, uterus or both
- 4 Main Types:
  1. Cystocele/Dropped Bladder: Protrusion involves the front (posterior wall) of the vagina and rectum (Most common type)
  2. Rectocele: Involves the back (posterior wall) of the vagina and rectum
  3. Enterocele: Involves the upper portion of the vaginal wall and small bowel
  4. Uterine Prolapse: When the uterus descends downwards

Causes

- Anything that puts increased pressure in the abdomen
- Pregnancy, labour and childbirth
- Obesity
- Constipation
- Pelvic organ cancers
- Hysterectomy
- Genetics
- Connective tissue disorders
- Selective estrogen-receptor modulators
- Advancing age

Symptoms

- Vaginal
  - Sensation of a bulge/protrusion
  - Seeing or feeling a bulge/protrusion
  - Pressure
  - Heaviness
- Urinary
  - Incontinence
  - Urgency
  - Frequency
  - Weak/prolonged urinary stream
  - Hesitancy
  - Feeling of incomplete emptying
  - Manual reduction of prolapse to start/complete voiding
  - Position change to start/complete voiding
- Bowel
  - Incontinence of flatus, or liquid or solid stool
  - Feeling of incomplete emptying
  - Straining during defecation
  - Urgency to defecate
  - Digital evacuation to complete defecation
  - Splinting/pushing on or around the vagina/perineum, to start of complete defecation
- Sexual:
  - Dyspareunia (pain with sex)
  - Decreased sexual desire due to body image issues associated with prolapse

Diagnosis

- Routine pap smear
- Pelvic ultrasound
- Intravenous Pyelogram (IVP): Urinary tract x-ray
- CT/MRI scan: Of the pelvis

Treatment

- Pelvic Physiotherapy: To strengthen the pelvic floor muscles
- Pessary: Device is inserted into the vagina to provide support to related pelvic structures and to relieve pressure on the bladder and bowel
  - A wide variety of pessaries (made of silicone/plastic) are available for those who are not candidates for surgery or have temporary issues post-pregnancy
  - Fitted based on the nature and extent of the prolapse and the patient’s cognitive status, manual dexterity and level of sexual activity
  - Size of the vagina is estimated and the appropriate size and shape of pessary is inserted to effectively reduce the prolapse
- Reconstructive Surgery: Aims to correct the prolapsed vagina while maintaining/improving vaginal sexual function and relieving any associated pelvic symptoms
  - - Can be done through an abdominal incision/laparoscopically/vaginally
- Sacrocolpopexy Surgery: Suspends the upper vagina with synthetic mesh
  - - - Can be done through an abdominal incision/laparoscopically
- Vaginal Surgery: Either the upper vagina/cervix is attached to the ligament between the ischial spine and the sacrum (sacrospinous ligament) or to the ligaments between the sacrum and uterus (uterosacral ligaments)
- Obliterative Surgery: Closes off the vaginal canal either partially/completely
  - Typically reserved for women who are no longer sexually active

POLYCYSTIC OVARIAN SYNDROME (PCOS)

About

- Common condition that affects how women’s ovaries work
- Three main features include:
  - Irregular periods
  - Excess androgen
  - Polycystic ovaries: Enlargement of ovaries containing many fluid-filled sacs that surround the eggs
- Sacs are often unable to release an egg, resulting in no ovulation
- Most women discover they have PCOS in their twenties and thirties due to infertility issues, but it can happen at any age after puberty
- Affects between 5-10% of women 15-44

Potential Causes

- Exact cause is unknown, but is often hereditary (specific genes associated with PCOS have not yet been identified)
- Increased production and activity of hormones
- Resistance to insulin
- Hormone imbalance

Symptoms

- Irregular periods or no periods at all
- Difficulty getting pregnant as a result of irregular ovulation or failure to ovulate
- Excessive hair growth (hirsutism) – usually on the face, chest, back or buttocks
- Weight gain
- Thinning hair and hair loss from the head
- Oily skin/acne
- Increased risk of developing Type 2 Diabetes, high blood pressure and high cholesterol

Diagnosis

- Medical history
- Blood pressure check
- Transvaginal ultrasound: To determine whether you have a high number of follicles in your ovaries
- Blood test: To measure hormone levels and screen for diabetes and high cholesterol

Treatment

- Lifestyle: Healthy eating and regular exercise to maintain a healthy weight
- Oral medications: To treat hair loss, irregular periods and infertility
- Surgery: For fertility if medication fails
- Laparoscopic Ovarian Drilling (LOD): Electrocautery/a laser is used to destroy the tissue producing androgens (male hormones), thus correcting hormonal imbalance and restoring the normal functioning of the ovaries

uterine fibroids

About

- Benign growths that are made up of the muscle and connective tissue of the uterine wall
- May grow as a single nodule or in clusters and may range in size from 1 mm to more than 20 cm (8 inches) in diameter
- They may grow within the wall of the uterus, project into the interior cavity or toward the outer surface of the uterus
- In rare cases, they may grow on stems projecting from the surface of the uterus
- Symptoms, size, location and number vary
- Each fibroid is unique and one of a kind, which requires individualization of therapeutic options

Potential Causes

- Unknown
- Most fibroids occur in:
  - Women of reproductive age
  - Black women diagnosed 2-3x more frequently than white women
  - Seldom seen in young women who have not begun to menstruate
- Increased risk with
  - Genetic link
  - Obesity
  - Not having children
  - Early onset of menstruation
  - Late age for menopause

Symptoms

- Most fibroids do not cause any symptoms
- Symptoms usually stabilize/dissipate post-menopause
- Some women may have the following:
  - Excessive/painful bleeding during menstruation
  - Bleeding between periods
  - A feeling of fullness in the lower abdomen
  - Frequent urination resulting from a fibroid that compresses the bladder
  - Pain during sexual intercourse
  - Low back pain
  - Constipation
  - Chronic vaginal discharge
  - Inability to urinate
  - Severe menstrual cramps
  - Infertility

Diagnosis

- Pelvic exam: To detect if the uterus is enlarged/irregularly shaped
- Abdominal ultrasound: To get a picture of your uterus and to map and measure fibroids

Treatment

- If asymptomatic, no treatment is necessary
- Periodic pelvic examination and ultrasound depending on the size or symptoms of the fibroid/s
- Type of treatment is determined by the number, size, location and symptoms
- Laparotomy: Abdominal incision to remove all fibroids
  - More often used when there are a large number of fibroids
- Uterine Fibroid Embolization (UFE): Minimally invasive procedure that uses a form of real-time x-ray called fluoroscopy to guide the delivery of embolic agents to the uterus and fibroids
  - These agents block the arteries that provide blood to the fibroids and cause them to shrink
  - Nearly 90% of women who undergo UFE experience significant/complete resolution of their fibroid-related symptoms

VAGINAL ATROPHY

About

- Vaginal tissue no longer functions normally, as the lining of the vagina begins to shrink/thin out
- Also known as “Genital Syndrome of Menopause”
- Often occurs in women during menopause due to the loss of estrogen
- Can also occur in younger women who have a decrease in estrogen

Causes

- Lower estrogen production as a result of menopause
- The lining of the vagina can become thinner and less stretchy and the vaginal canal can narrow and shorten
- Less estrogen lowers the amount of normal vaginal fluids and changes the acid balance of the vagina
- Lower estrogen levels can also occur in women who have just given birth and are breastfeeding, have had their ovaries removed or are taking certain medications (aromatase inhibitors for breast cancer treatment)

Symptoms

- Vaginal dryness
- Vaginal burning
- Vaginal discharge
- Genital itching
- Burning with urination
- Urgency with urination
- Frequent urination
- Recurrent urinary tract infections (UTIs)
- Urinary incontinence
- Light bleeding after intercourse
- Discomfort with intercourse
- Decreased vaginal lubrication during sexual activity
- Shortening and tightening of the vaginal canal

Diagnosis

- Pelvic exam: Pelvic organs are felt and your external genitalia, vagina and cervix are visually examined
- Urine test: To check for blood/abnormalities if you have urinary symptoms
- Acid balance test: A sample of vaginal fluids is taken with a paper indicator strip to test its acid balance

Treatment

- Lotions & Oils: Add moisture and loosen the vagina to improve comfort during sex
- Moisturizers: For irritation and dryness similar to a skin moisturizer
- Personal Lubricants: Best used to minimize friction and relieve vaginal dryness during intercourse
  - Not recommended to use Vaseline (can lead to yeast infections), olive/Vitamin E oil (can cause an allergic irritation in the vaginal area) or Mineral oil
- Dilators: Devices to widen (dilate) the vagina to enable you to go back to having sex without pain
- Hormone Therapy: Brings back the health of the skin by restoring the normal acid balance of the vagina, thickening the skin (back to how it was originally), maintaining natural moisture and improving bacterial balance
- Dilators used in conjunction with local hormone therapy for best results
- Vaginal Estrogen Therapy: Helps restore normal vaginal pH
  - Cream form: Estradiol/conjugated estrogens
  - Pill form: Inserted into the vagina
  - Ring form: Left in the vagina and replaced every 3 months
- Vaginal Laser Therapy: To restore the function of the vaginal area
  - Can help with painful intercourse, dryness and laxity
- Hormone Replacement Therapy (HRT)/Systemic Hormone Therapy: Taken orally in higher doses
  - For those who have additional menopausal symptoms
- Ospemifene (Osphena): Non-estrogen pill that is taken orally
  - Its benefits to the vagina are similar to that of estrogen

VAGINISMUS

About

- Vaginal muscles squeeze/spasm and cause pain during intercourse, a Pap test or the insertion of a tampon
  - Primary/Lifelong: Pain experienced every time something enters the vagina
  - Secondary/Acquired: A woman has had sex without pain before, but then it becomes difficult/impossible

Potential Causes

After menopause due to the drop in estrogen levels (Vaginal atrophy)
After a surgery/trauma
Past sexual abuse
Fear/negative emotions about sex
Anxiety

Symptoms

- Difficult/impossible penetration of the vagina due to muscle tightening
- Burning/stinging pain and tightness of the vagina if penetrated by a tampon, finger or penis
- Intense fear of penetration and avoidance of sex
- Loss of sexual desire if penetration is attempted

Diagnosis

- Describe symptoms to your doctor
- Pelvic exam: To rule out other conditions

Treatment

- Progressive Desensitization: Squeezing and relaxing exercises to learn to control and relax the vaginal muscles
- Vaginal Dilator therapy: Smooth tampon-shaped objects in different sizes to help you gradually get used to having something inserted into your vagina
  *Anesthetic creams can be applied until you get used to them
- Psychosexual therapy: Aims to help you understand and change your feelings about your body and sex (for those whose vaginismus stems from fear/anxiety)
- Relaxation techniques: Mindfulness, breathing and gentle touching exercises to help you learn to relax the vaginal muscles

Vulvodynia/Vestibulodynia

About

- Chronic vulvar pain with an unknown cause
- The location and severity of pain can vary among sufferers
- Some women will experience pain in one area of the vulva, while others will experience pain in multiple areas
- 2 main subtypes
  - Localized Vulvodynia: Pain experienced at only one vulvar site
    - Provoked Vestibulodynia (PVD): Pain limited to the vestibule occurring before/after pressure is applied to the vestibule ie: sexual intercourse, gynecologic exams, tampon insertion, sitting for extended periods of time, wearing tight pants
    - Vestibulodynia: Pain in the vestibule (the tissue surrounding the vaginal opening)
    - Clitorodynia: Pain in the clitoris, less common form of localized vulvodynia
  - Generalized Vulvodynia
    - Pain can occur spontaneously and can be fairly constant, although there can be periods of relief from symptoms
    - Activities that apply pressure to the vulva can often make symptoms worse ie: sexual intercourse, sitting for extended periods of time, wearing tight pants
    - Some women may experience pain in a specific area while others can experience pain in multiple areas even including the perineum and inner thighs

Potential Causes

- Researchers speculate that one or more of the following may cause/contribute to the condition:
  - Pelvic floor dysfunction
  - Past vaginal infections
  - Allergies/sensitive skin
  - Hormonal changes
  - Injury/irritation of the nerves surrounding the vulvar region
  - Increase in sensitivity of pain-sensing nerve fibres in the vulva
  - Abnormal vulvar cell response to environmental factors such as infection/trauma
  - Genetic susceptibility to chronic vestibular inflammation, chronic widespread pain and/or inability to fight infection

Symptoms

- Pain/burning near the opening of the vagina, and sometimes only when something touches that area
- Pain on/around the vulva, even when nothing touches that area
- Burning/Stinging
- Itching
- Swelling
- Throbbing
- Rawness
- Painful intercourse (dyspareunia)
- Flares up during and after sexual intercourse, wiping, sitting on a bicycle or inserting a tampon

Diagnosis

- Medical, sexual and surgical history and symptom evaluation
- Vaginal exam: Vulva, vagina and vaginal secretions are checked to rule out an infection/skin disorder
- Blood test: To assess hormone levels
- Cotton-swab test: To gently check for specific, localized areas of pain in your vulvar region

Treatment

- Oral Medications:
  - Pain medications: Steroids, tricyclic antidepressants, anticonvulsants
  - Antihistamines: To reduce itching
- Topical Medications
  - Hormonal creams
  - Local anaesthetics: Lidocaine
  - Compounded formulations
- Discontinuation of irritants (ie: laundry detergent, soaps, etc)
- Pelvic Floor Physiotherapy
- Biofeedback Therapy: Teaching you how to relax your pelvic muscles and control how your body responds to the symptoms
- Nerve Blocks
- Surgery: To remove the affected skin and tissue (vestibulectomy) in cases of localized vulvodynia or vestibulodynia