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Gynaecology
Bleeding after the menopause (postmenopausal bleeding)
A woman is considered to be menopausal when a year has passed since her last period. Any bleeding after this time is always considered to be potentially abnormal. In fact only a small proportion of women who bleed after the menopause have anything significantly wrong. However as occasionally such bleeding can be a sign of pre-cancerous changes or even cancer, it is important that it is investigated thoroughly.
Once oestrogen levels drop after the menopause the skin of the vagina becomes thinner, and bleeding may result from this. Problems with the cervix may also be a causative factor. So any assessment must include a cervical smear, which will mean that the skin of the vagina will be examined as part of this procedure.
The role of ultrasound
Bleeding may also come from the lining of the womb or endometrial cavity. Normally the lining is very thin as there is little oestrogen circulating to stimulate it. This lining can be measured using ultrasound, furthermore any other problems in the cavity of the uterus (womb) can also be seen. There are many studies that show that if the lining of the uterus is thin (< 5mm), then it is very unlikely that there is anything significantly wrong. In this way ultrasound can be used to reduce the need for unnecessary more intrusive investigation. If the endometrial thickness is increased then it is still unlikely that there is anything seriously wrong, but to exclude this a small sample of the womb lining needs to be examined in order to exclude problems (taking a biopsy). This can be carried out as an outpatient in some cases, but may require an examination under a brief general anaesthetic.
Less commonly bleeding may be secondary to ovarian cysts or disease of the fallopian tubes. An ultrasound scan can be used to detect any ovarian or tubal pathology and appropriate action advised.
Ovarian Cysts
A cyst is a fluid filled sac and does not in itself indicate a specific diagnosis. In younger women by far the majority of ovarian cysts are related to ovarian function (physiological). For example if ovulation does not occur, a small cyst may develop. In these circumstances if such a cyst is seen on ultrasound, a repeat examination in six weeks is advised to check for resolution. These cysts that relate to ovarian function can cause pain and on occasion treatment is required.
The ovary is made up of different types of cells that have different roles. There are many types of cysts that are benign growths, the different nature of these cysts reflect the cell type that they originate from. In young women probably the most common cysts that we see are benign cystic teratomas (dermoid cysts) or endometrioma’s. Again just because a cyst is present does not mean it has to be removed – however surgery is usually recommended in these cases unless the cyst is very small. These growths of the ovary can cause pain and occasionally they may cause the ovary to become twisted. The likelihood of these complications occurring is thought by some to depend on the size of the cyst. It is generally thought that complications are more likely if the cyst is more than 5 cm in largest diameter.
Towards the menopause and beyond the presence of an ovarian cyst is likely to cause more concern. Although ovarian cancer is in fact a relatively uncommon disease, it becomes more common with increasing age. Again benign cysts are more common. These are characterised by having a smooth internal wall and clear fluid contents. These cysts are called benign cystadenomas and they originate from the tissue that covers the ovary (called the epithelium). Unfortunately some ovarian cysts will turn out to be malignant (cancerous) although it must be emphasised that most ovarian cysts are benign.
Diagnosis
Ultrasound is used as the main tool to diagnose ovarian cysts. However a scan should in most cases indicate not only that a cyst exists, but also give an opinion on the type of the cyst that is present. Many common cysts such as teratomas and endometriomas have a characteristic appearance. Nearly all cysts that have a smooth internal capsule and clear contents (called “simple”) are completely benign. Cancers tend to be associated with an irregular internal cyst wall and solid projections of tissue into the cyst cavity.
Management
In young women many ovarian cysts will resolve spontaneously without intervention. For other cysts a “watch and wait” policy may be adopted – with the cyst being monitored over a period of time.
If intervention is required then for most benign cysts laparoscopic (keyhole) surgery will be possible, although this will not be possible in all cases. Should the cyst be too large or the patient has undergone previous surgery a conventional “open” approach may be needed to remove the cyst.
After the menopause a less conservative approach is often taken and removal of an ovary because of an ovarian cyst is more likely. In the unlikely event that a cyst has features of cancer then surgery should be performed by a sub-specialist trained in gynaecological oncology.
Pelvic Pain
Pelvic pain is a common symptom in women of all ages. In some cases no specific cause can be found, but being reassured that there is no serious underlying problem can be helpful. Taking a full history and a conventional gynaecological examination is an important part of the assessment of pelvic pain, however an ultrasound scan can be particularly helpful. A normal ultrasound scan means that it is unlikely that there is any significant underlying problem causing the pain, in other words ultrasound has a high negative predictive value.
Acute Pain
Pelvic pain can be described as acute or chronic. Acute pelvic pain relates to pain that is of recent onset and may be severe. In young women there are many possible causes for this. In this situation it is important to carry out a pregnancy test as occasionally such pain can be caused by an ectopic pregnancy. Other common causes of acute pain include complications of ovarian cysts (torsion and rupture) and pelvic infection. Even ovulation can cause a surprising amount of discomfort.
A scan is helpful to clarify the situation as ultrasound will demonstrate most ectopic pregnancies and identify complications of ovarian cysts as well as see some tubal problems associated with pelvic infection. It must be remembered that acute pelvic pain is not always of gynaecological origin. Appendicitis, gastroenteritis, and urinary infection are just some of the conditions that need to be considered in this situation.
Chronic Pain
Previous Pelvic Infection
Longstanding or chronic pelvic pain may have different causative factors to acute pain, although there may be some degree of overlap. Again for women with chronic pain, a normal scan means that it is very unlikely that there is any serious underlying gynaecological problem. Previous pelvic infection may lead to chronic pain and be associated with the presence of swellings of the fallopian tubes (hydrosalpinges). These can usually be demonstrated by ultrasound. Inflammation may also lead to the formation of adhesions. These cannot generally be seen with ultrasound, but their presence may be inferred if there is reduced ovarian mobility, fixed areas of fluid within the pelvis or tenderness at the time of the scan.
Endometriosis
However a condition called endometriosis is perhaps one of the most common causes of chronic pain. Women with endometriosis may have a typical type of cyst in the ovary (endometrioma’s). They also tend to have pain in specific areas at the time of a scan as well as rather reduced ovarian mobility. For a definitive assessment a procedure called a laparoscopy is often performed in these circumstances to visualise the presence of endometriosis directly in the pelvis. As with acute pain other non-gynaecological causes of pain such as irritable bowel syndrome (IBS) or diverticulitis must be considered.
Fibroids
Less commonly fibroids may be a cause of chronic pain. This can occur when the inside of the fibroid undergoes degeneration. Pain is more likely when the fibroid is attached to the uterus by a thin stalk. Such fibroids are called “pedunculated” and can be associated with the fibroid twisting on its blood supply (torsion).
Problem Periods
Heavy Periods (menorrhagia)
Many women are troubled by heavy periods, and some by bleeding between periods. In young women these symptoms are not always investigated but tend to be treated symptomatically, for example by taking the oral contraceptive pill. In some cases bleeding will be due to an underlying problem, and an ultrasound scan may be performed to exclude or diagnose some of these conditions. Probably the most common disorder leading to bleeding problems is uterine fibroids, but other problems include polyps inside the cavity of the uterus and abnormalities of the lining of the uterus itself (endometrium).
Fibroids within the cavity of the uterus and polyps can be demonstrated using ultrasonography. In selected cases the patient can be offered keyhole (hysteroscopic) surgery to remove them. If the lining of the womb (endometrium) looks thin on ultrasonography it is unlikely that there is any disease present. However when a scan shows that the lining is thickened further investigation may be needed. This will usually mean that a small biopsy from the lining of the uterus will be considered. This can usually be performed in the clinic.
Treatment
The treatment of heavy periods varies. For many, reassurance that there is no serious underlying problem is enough. For others simple tablet treatment will be all that is needed (tranexamic acid or the combined oral contraceptive pill). More recently a type of coil called the Mirena IUS has been shown to be very effective at making periods lighter. If a polyp or fibroid has been shown in the cavity of the uterus then keyhole surgery to remove them may solve the problem.For larger fibroids in the wall of the uterus conventional “open” surgery or keyhole surgery may be appropriate depending on their size and position.
For some fibroids a technique called embolisation may be suitable. This technique avoids surgery and is based on a technique that blocks some of the blood supply to the uterus leading to shrinkage of any fibroids present. It must be remembered that for most women with bleeding problems there is no serious underlying problem.
For some the problem is due to a change in the function of the ovaries. With increasing age the ovaries may become less efficient and ovulation may not occur with every menstrual cycle. An ultrasound scan at this time may demonstrate a "physiological" cyst on the ovary and and an endometrium (womb lining) that is not synchronous with the stage of the cycle. This is a physiological problem that can be managed symptomatically.
Bleeding between periods
Bleeding between periods (intermenstrual bleeding) is often thought to be more likely to be associated with there being a underlying problem than heavy bleeding at the time of an expected period.
Typically a polyp may be present on the cavity of the uterus, and this may be demonstrated by an ultrasound scan. However abnormalities of the cervix or infection may also be associated with this symptom and should be excluded.
Absent or irregular periods
There are several reasons why periods may stop or become irregular. Some can be clarified on the basis of blood tests to measure the levels of circulating hormones. One condition called polycystic ovaries can be demonstrated using vaginal ultrasonography. This is probably one of the most common causes of irregular and absent periods.
Polycystic ovaries is an unfortunate term as it implies the ovary contains cysts - which it does not. The ovaries contain several follicles and the condition represents a disorder of ovarian physiology and in some cases metabolism.
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