In this section you will find descriptions of some major gynecologic conditions and procedures. We hope this section will be informative and educational. If you would like a more in-depth discussion about any of these conditions or procedures, please give our office a call at 206.709.8600. This section is not meant to replace a face-to-face discussion with Dr. South.
Conditions
Abnormal Menstrual Periods
The most common reason a woman consults a gynecologist is for abnormal periods. This symptom should never be ignored because it could be an early sign of cancer. Therefore, if your periods become abnormal, you should seek medical attention immediately Abnormal menstrual periods may occur as:
- very profuse, but regularly occurring periods
- marked irregularity of bleeding
- bleeding or spotting between periods
- bleeding after intercourse
- prolonged episodes (weeks or months) of bleeding
- irregular bleeding around the menopause
- bleeding occurring well after natural menopause
- bleeding occurring while taking hormone treatments
- bleeding occurring just three or four times a year
- absence of menstruation, either during teenage years or later in life.
Treatments: Many types of abnormal bleeding are not cause for alarm, while others require evaluation and testing. Only an office visit can help determine this. If further information is needed, a vaginal ultrasound and a sampling of tissue inside the uterus will provide the information we need. Once these tests are run, additional treatment in the form of hormone therapy, medication or possibly surgery may be indicated. If surgery is necessary, there are many different operations, including hysterectomy. New possibilities: In many cases, a new, very exciting technique known as endometrial ablation can be performed. It is a brief, outpatient procedure during which a device is inserted into the uterine cavity to destroy the uterine lining.
Abnormal Pap Smear
Abnormal Pap Smears occur in about fifteen percent of patients. Rarely do they show cancer.
Symptoms: There are no symptoms. That is why an annual Pap smear is so important. Recently it has been recommended that a woman may have Pap smears less often than yearly if she meets certain criteria. In Dr. South's opinion, an annual Pap smear is still the safest course. It has also been reported in the press that Pap smears are not necessary after hysterectomy. This is only true if the hysterectomy was performed for a non-cancerous condition. Remember, even though the Pap smear issue may be debatable, every woman needs a yearly well-woman exam!
Diagnosis and Treatment: Some Pap smears may show infections such as yeast and treatment can be started. Also shown sometimes is the human papilloma virus (HPV). This is a sexually transmitted condition that is associated with precancerous changes in the cervix. When a Pap smear suggests pre-cancerous changes further evaluation is necessary. That evaluation is called a colposcopy. The cervix is viewed through an instrument under magnification. If a suspicious lesion is seen it can be biopsed (a small punch of tissue removed). If a pre-cancerous condition is diagnosed it is call dysplasia. In the past this disease was usually treated by freezing (cyro) but the most common treatment is LEEP. (See procedures) Under either local or general anesthesia a quarter-sized disc of tissue is removed from around the cervical opening.
Frequently an abnormal Pap smear will revert to normal. Unless the abnormality is severe or HPV virus is present, it is almost always possible to re-check the Pap in 1-2 months to be sure it is truly abnormal.
Endometriosis
Endometriosis is a common gynecologic condition in which the lining of the uterus grows in places outside of the uterus - commonly on the ovaries and supporting ligaments of the uterus.
Symptoms: The main symptoms are abnormal periods, pelvic pain, painful periods, painful intercourse, and painful bowel movements at the time of menstruation. Although this condition can be suspected from the history and examination, a laparoscopy is needed to establish the diagnosis.
Treatment: Often, at the time of laparoscopy, the endometriosis
implants can be cauterized or treated with LASER. If the disease is mild
and fertility is not an issue, frequently no treatment is necessary. Another
approach is to shrink or dissolve the endometriosis with a drug called Lupron.
The drug is usually given for six months by monthly injections. Unfortunately,
the endometriosis will return after the drug is discontinued.
"Conservative" endometriosis surgery is an operation, either as open surgery or a laparoscopic procedure in which all possible endometriosis is removed while still retaining the possibility of pregnancy.
"Definitive" endometriosis surgery is usually a hysterectomy with removal of both ovaries. If performed in a young woman, hormone replacement is necessary.
When infertility is a part of endometriosis and conservative surgery does not result in a pregnancy, the patient may be treated by insemination with the partner's or donor's sperm or other assisted reproduction techniques. (IVF)
Family Planning
Dr. South can help you with all aspects of family planning. Different options are listed below.
Condoms and Spermacide: A popular method
of birth control that also helps prevent STD's. Failure rate about 5 %.
Diaphragm: A latex device placed in vagina prior to intercourse that
covers the cervix. Rarely used any more.
Injectable Contraceptives
(Depo Provera): Injection given every three months. Highly effective. Very
convenient. By
second shot most women have no periods. Some patients may gain weight
or have PMS symptoms. May take up to eighteen months to conceive after stopping.
IUD's: Dr. South is presently using Mirena. Works by foreign-body activity
and hormone-release to prevent conception. Sometimes causes increased
flow and cramping. Extremely convenient. Newer IUD's extremely safe. Best
in women who have delivered a baby. Small failure rate.
Oral Contraceptives:
Used by
millions of women. Risks very, very low. New doses practically side
effect free. Same concept now available as a skin patch or vaginal ring. Failure
rate very low.
Rhythm: Timing intercourse to avoid a women's fertile period. A very high
failure rate.
Tubal Ligation: An operation to block the Fallopian
tubes. Usually performed laparoscopically. Tubes usually cauterized which "welds" them
shut. Permanent reversal not very successful. Small failure rate.
Gynecologic Cancers
CERVICAL CANCER - A major cause of death in the third world where
there are no Pap smears. Can be prevented by the annual Pap smear.
Early forms
(carcinoma-in-situ) are completely curable. More advanced forms are
uncommon in the US except for the medically indigent.
Treatment: Early forms
are treated
by LEEP if pregnancy is desired. If pregnancy is not an issue treatment
may sometimes be a hysterectomy. More advanced forms require radical surgery
or
radiation treatment.
FALLOPIAN TUBE CANCER -extremely rare. Very similar to ovarian cancer.
OVARIAN CANCER - The worst of all female cancers and there is no
screening test. Research is working hard to find an early-warning
test
Symptoms: Major symptom is bloating. Always report that symptom to
your doctor Some element of family history present.
Treatment: Radical removal of all cancers present and usually chemotherapy. The outlook is much better now due to new forms of chemotherapy and radical surgery. Many patients go into remission for an extended period.
UTERINE (ENDOMETRIAL) CANCER - cancer of the body of the uterus.
Most commonly diagnosed between age fifty and seventy. Clear-cut
risk factors
- obesity, high blood pressure, diabetes, history of infrequent periods.
No screening test. (Pap smear is not a test for this cancer.)
Symptoms: Usually diagnosed by investigating abnormal
bleeding.
Treatment: Treated by hysterectomy and radiation
if more advanced. In early cases nearly 100 per cent are cured.
VAGINAL CANCER - extremely rare
VULVAR CANCER - cancer of the skin of the outside of the
vagina. Usually seen in elderly women. Occasionally early forms in young
women.
Symptoms: Often associated with itching and burning.
Treatment: Treated by surgical removal. Can be completely cured if
caught early. If advanced the outlook is poor. Only screening is
an annual well-woman exam.
And last…BREAST CANCER - Remember, your gynecologist is your first line of defense against breast cancer. He or she does your breast exam and supervises your mammogram program. If a breast lump cannot be felt and is picked up on a mammogram - cure is as high as 95-100%.
Gynecologic Infections
BACTERIAL VAGINOSIS (BV) A common vaginal infection. Currently associated
with pre-term labor.
Symptom: yellow discharge.
Treatment:This infection can be treated orally or vaginally.
CHLAMYDIA This is an infection in the uterus and fallopian tubes.
Symptom: Vague abdominal pain.
Treatment: The treatment is antibiotics. If unrecognized it may
damage the tubes and cause infertility.
HERPES The most important infection of the vulva. This is a sexually
transmitted disease. It often remains in both the female and the
male in a dormant state for many years. Herpes can be spread in the
absence of any symptoms.
Although it is very bothersome, it is not a serious disease unless
it occurs in late pregnancy. In that event, a Cesarean section is
often performed to
protect the baby.
Symptoms may not exist or there may be painful
blisters on the vulvar skin.
Treatment is only partially effective. Condom use is advised. Drugs
such as acyclovir reduce the severity of the infection and the number
of outbreaks but do not eliminate the virus.
HUMAN PAPILLOMA VIRUS (HPV) Another important infection of the vulva,
vagina, and cervix. It is sexually transmitted and very common. It
often causes
warts which are called condylomata. This virus is often found on
Pap smears where it is involved in the development of cervical cancer.
Symptoms: Itching
and warts.
Treatment: There is no medical cure for the infection. The warts
are usually treated by chemicals or LASER. When the virus is found
on a Pap smear, it is diagnosed and treated as any abnormal Pap smear.
PELVIC INFLAMATORY DISEASE The most severe pelvic infection. This
sexually transmitted disease is caused by a variety of bacteria,
among them gonorrhea.
Symptoms: Pain and fever.
Treatment: This
infection may require hospitalization and intravenous antibiotics. Occasionally
abcesses may form. Early "complete" hysterectomy
may occasionally be necessary.
YEAST INFECTION This infection is extremely common.
Symptoms: Usually there is burning and itching and a
cottage cheese-like discharge is produced.
Treatment: Is with suppositories, creams,
and the oral medicine, Diflucan.
Infertility
Because infertility evaluation is often not covered by insurance, it is important the testing be done quickly and efficiently, avoiding unnecessary tests. recommend a complete gynecologic exam, including an ultrasound and a test to confirm the tubes are open, as well as a semen analysis. Unless endometriosis is suspected, laparoscopy can usually be avoided. In-vitro fertilization (IVF) is about 40 percent effective, but expensive, with a cost of $12,000 to $15,000 per treatment. Intra-uterine insemination using the male partner's sperm is a good option for many, and is far more affordable.
Ovarian Cysts
Ovarian cysts are fluid-filled growths that occur on the surface of the ovary. They are very common. Many cysts are functional. That means that they are just an exaggerated form of ovulation. In other words, a small bleb forms on the ovary but grows rather than shrinks. A cyst is usually no larger than a tennis ball and disappears in one to three months. When cysts are larger, persistent, or have an abnormal appearance on ultrasound, they may require surgery. Usually the cyst can be removed and the ovary saved. Fifteen per cent of women will have surgery on their ovaries in their lifetime. The gynecologist's goal is not to operate too much, but to be aggressive enough not to miss an ovarian cancer. Vaginal ultrasound is the key to achieving this balance and surgery is only recommended when necessary.
Premenstrual Syndrome (PMS)
The feelings many women have prior to their menstrual periods are known by about everyone. An estimated 70 percent to 90 percent of menstruating women experience some form of PMS. Symptoms include weight gain, abdominal cramping, breast soreness, irritability, depression and lack of concentration in the days before their period. For many years these symptoms have been grouped together and called PMS. We now divide this condition into mild and severe forms. The mild form, pre-menstrual syndrome (PMS) is generally well tolerated by the patient and often requires no treatment other than understanding from family and coworkers. The severe form, pre-menstrual dysphonic disorder (PMDD) is far more severe and may impair relationships. It may also interfere with proper decision-making. This cause of this condition in the past has focused on hormonal imbalance. This idea is now thought to be incorrect. The current explanation involves changes in brain chemicals (neurotransmitters). That explains why certain anti-depressants “cure” PMDD in an almost magical way. Not every patient requires this therapy of course.
One last thought - PMS/PMDD is not “in your head,” It is a biochemical disorder, modified by emotion to be sure, and should be taken seriously by a physician or health-care provider.
Prolapse
Prolapse is the medical word for weakness or protrusion of the vagina or uterus or both. This is a very common problem. It is becoming more common as women live longer and lead more active lives.
Symptoms:
Extremely annoying
to many women, this condition is caused by tearing and stretching
of the vaginal tissues and uterine supports during childbirth. In
mild forms it may be just
a sense of vaginal pressure and in it's severest form the vagina
may be completely turned “inside-out!”
Treatment: Although pelvic exercises and biofeedback may
help, the only sure treatment is vaginal reconstructive surgery. (See
procedures) This surgery consists of incisions in the vagina to tighten and support
the vaginal,
bladder and rectum tissues. Two or three days in the hospital are
usually required and about one month of recuperation on average.There
are many new
and exciting developments in the field of gynecology. Different grafts
and surgical techniques allow for better results and faster recovery.
On average, about 80 per cent of women have an excellent result from
this surgery.
Stress Incontinence
If a woman reaches fifty without cancer or heart disease, her life expectancy is 85! Almost 30% of women are still working past age seventy. At least one-third of these women will have urinary leakage or incontinence.
Symptoms: Stress incontinence is the medical term for this condition and it means loss of urine when you cough, laugh, or sneeze. It can also occur with sports such as swinging a golf club or tennis racquet. For some women this symptom is minor and tolerable but for others it requires the wearing of a pad or even clothing changes during the day. Fortunately there are exciting new ways to treat this condition. The major cause of this symptom is tearing of the muscles and tissues of the vagina during childbirth. As a result most women with incontinence will have weakness in the vagina and sometimes outright protrusion beyond the vaginal opening.
Treatment: One or more of these procedures may be used
- Test that measure urine pressures. These are painless and establish the correct diagnosis.
- Biofeedback techniques to retrain the bladder
- Drugs that relax the spasm in the bladder.
- Surgery that partially obstructs the urinary opening - often as an outpatient with minimal sedation only.
- Surgery that tightens the weakened vaginal tissues and elevates the bladder. Performed as an in-patient.
With this new technology it is no longer necessary for women to put up with this symptom.
Uterine Fibroids
Uterine fibroids are non-cancerous, spherical tumors that grow in the muscular wall of the uterus. Some have said that fibroids are the most common "disease" of women. Fibroids can be pea-sized or the size of a volleyball!
Symptoms: Fibroids often cause no symptoms and can simply be followed. When symptoms are present they are usually a dull, aching pain in the lower abdomen and there are profuse menstrual periods.
Treatment: Treatment options are as follows:
- Simple observation with examination every six months
- Drugs that temporarily shrink the tumors
- Myomectomy in which the tumors are removed without hysterectomy
- Hysteroscopy which removes fibroids by using a scope placed in the uterine cavity
- Embolism which denies the blood supply to the fibroid tumor (performed by the radiologist)
- Hysterectomy
In our practice we have on-site vaginal ultrasound, which may diagnose these tumors at an early stage. If hysterectomy is required, Dr. South is an experienced gynecologic surgeon, having performed over 5,000 surgeries on the female reproductive organs.
PROCEDURES
Bone Density Testing
Bone density testing determines the so-called "thickness" of the bones and whether osteoporosis is a concern. The testing may be performed as a complete body scan or a simple heel scan. The heel scan, which can be done in our office, is painless. Most insurances pay for this relatively inexpensive scan. The procedure, which uses a very low-level X-ray to read bone density, takes only about 15 seconds, and provides immediate results. There are several new drugs available for the prevention and treatment of osteoporosis.
Cervical Biopsy
An office procedure in which a small pinch of tissue is removed from the cervix. The biopsy is used in the diagnosis of the abnormal Pap smear. This procedure is nearly painless and is performed in association with colposcopy
Colposcopy
This painless examination, performed because of an abnormal Pap smear, involves looking at the cervix under magnification. When dilute vinegar is placed on the cervix, characteristic patterns, which may be pre-cancerous, are seen. These patterned areas can then be biopsied. With this information, further treatment can be planned - or avoided.
D & C (Dilation and Curettage)
This is a very old minor operation in which the cervical canal is dilated and the uterine cavity scraped. A pathologist then examines the removed tissue. This procedure is usually done under anesthesia but as an outpatient. If cancer needs to be ruled out and ultrasound or office biopsy is not adequate, a D & C is essential. The procedure is used less often now because of ultrasound.
Endometrial Ablation
A new treatment for abnormal or heavy menstrual periods. It requires that the uterine cavity be normal (no fibroids). Under anesthesia an instrument is placed in the uterine cavity, which destroys the uterine lining by heat or freezing. It is extremely safe and may "cure" the symptoms or, at least, delay hysterectomy. About 80 percent of patients are pleased with the results.
Endometrial Biopsy
An office procedure to investigate abnormal bleeding in which a slender tube is inserted into the uterine cavity and a small specimen obtained. No anesthesia is required. Discomfort is very minimal. It often makes a traditional D & C unnecessary.
Hysterectomy
Surgical removal of the uterus for a variety of problems such as pain, abnormal bleeding, fibroids and cancer. Ovarian removal may or may not be performed at the same time Performed on thousands of women annually, either through an abdominal incision or through the vagina. Criticized by certain health-care writers, the operation is actually very popular with American women. A recent study compared women's satisfaction with hysterectomy versus medical treatment for abnormal bleeding and pain, and the operation was far more popular.
Hysterosalpingogram
An outpatient procedure in the X-ray department to determine whether the tubes are open. A contrast material is injected through the cervix by the gynecologist and X-rays are taken. The injection may cause some mild cramping. The procedure is generally part of an infertility evaluation.
Hysteroscopy
A procedure in which the uterus is inspected through scope placed thru the cervix. Polyps and fibroids can be removed. Requires general anesthesia.
Insemination
The sperm, which has been specially treated, is placed directly into the cervix or, more often, directly into the uterus. A hysterosalpingogram and ultrasound are done prior to the insemination. The patient using an ovulation predicting kit at home chooses the proper time of insemination. If the woman doesn't produce eggs regularly, ovulation may be stimulated.
Laparoscopy
An operation used to diagnose the cause of pelvic pain and infertility or to perform a tubal ligation. Done through tiny incisions in the abdominal wall. This is usually an outpatient procedure. Many disorders can be treated with this technique - such as tubal pregnancies, ovarian cysts, adhesions and endometriosis.
LEEP (Loop Electrosurgical Excision Procedure)
Preferred method of treating pre-cancerous lesions of the cervix when hysterectomy is not required. A nickel to quarter-sized disc of tissue is removed from around the cervical opening. This is done under local or general anesthesia. Preferred over the older freezing technique because there is less scaring on the surface of the cervix. It does not make future Pap smears more difficult to perform.
Myomectomy
The removal of fibroid tumors from the uterus without hysterectomy. Often done because of pregnancy failure due to the fibroids. Generally not suited for older women with multiple fibroids. In that case, hysterectomy is the wiser course. A hospital procedure done under a general anesthetic. Usually requires an abdominal incision, although occasionally performed by laparoscopy.
Oophorectomy
Sometimes done with hysterectomy. Operation to remove benign cysts or tumors from the ovary when the ovary cannot be saved. Can by done laparoscopically. Sometimes use to prevent ovarian cancer when there is a family history of the disease.
Ovarian Cystectomy
The removal either through an incision or by laparoscopy of a benign ovarian cyst without removing the entire ovary.
Supracervical hysterectomy
An older method of hysterectomy in which the cervix is not removed. Now enjoying a rebirth because there may be less damage to ligaments that support the vagina. Some women feel sexual response is better if the cervix is not removed. If this method is chosen, Pap smears must be continued.
Urodynamic testing
An office procedure using a urinary catheter to determine various flows and pressures in the bladder. Used to identify the exact cause of leakage and to plan the proper surgery. This is not a painful test.
Vaginal Reconstructive Surgery
General term for various operations designed to tighten and support weakened vaginal tissues. Often performed with a vaginal hysterectomy.
Vaginal Ultrasound
A brief, painless test during which a small probe is inserted into the vagina. Essential part of an evaluation of pelvic pain and abnormal menstruation. Often used to measure the lining of the uterine cavity to rule out cancer. Tiny polyps, cysts and fibroids can be seen when they are not felt during the pelvic examination. Used widely in infertility testing and treatment. An essential tool in a modern gynecologist's office.
© 2010 Allen Gregg South, M.D.