Gynaecology

Intrauterine Device (IUD)

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An intrauterine device (IUD) is a type of birth control device that is inserted into the uterine cavity and provides long-term and reversible contraception. It usually comes in a small T-shaped device made of flexible plastic, generally measuring between 2 to 3 cm in width and length. This type of birth control is highly effective and convenient. The doctor puts the ІUD in your uterus by going through your vagina and cervix, either in the outpatient clinic setting or under anaesthesia in the operating theatre as per individual case requirements.

Different types of IUD
There are 2 types of IUD commonly available and widely used in the world

  1. Copper IUD – the T-shaped device has a copper wire coil wrapped around it. The copper acts as a spermicide (creating a toxic environment and disrupting the sperm’s ability to fertilise the egg in the uterus). It can cause changes in the uterine lining, making it less suitable for implantation. It is effective immediately after insertion. It can also be used as emergency contraception and can prevent pregnancy if inserted within five days of unprotected sex.

2. Hormonal IUD – it has a similar shape to the copper IUD but instead of copper, it contains a hormone reservoir that releases a small amount of progestogen, a synthetic hormone similar to natural progesterone. This hormone has effects on the cervical mucus, making it thicker and able to prevent the sperm from reaching the egg. It can cause thinning of the inner uterine layers, making it less likely for a fertilised egg to implant. There are several brands of hormonal IUD in the world, such as Mirena, Kyleena, Liletta, and Skyla. These can last between 3 to 7 years, depending on the brand. Many women who had a hormonal IUD inserted are likely to have lighter, less painful periods due to the thinned-out inner uterine lining. Some women will not get periods at all. The reduction or absence of period is not harmful. This is beneficial in those with heavy menstrual bleeding, severe period pain or those with certain gynaecological disorders. The menstrual periods or fertility will usually return to normal soon after removal.

Benefits of using IUD (copper or hormonal)

• Highly Effective: one of the most reliable forms of birth control, with more than 99% effective at preventing pregnancy,
• Long-term protection: Depending on the type, an IUD can provide protection for 3 to 10 years.
• Low Maintenance: convenient and does not require any further action to ensure effectiveness
• Reversible: does not affect future fertility and fertility returns quickly upon removal.
• Cost-Effective: the long-term costs are much lower compared to other methods of contraception.
• Non-Hormonal Option: The copper IUD provides a hormone-free method of birth control
• Hormonal type – significant reduction in menstrual flow and pain. Recommended for the treatment of heavy menstrual bleeding and certain gynaecological disorders such as adenomyosis or endometriosis.

What are the risks and disadvantages of an IUD?

  • Compared to condoms, an ΙUD does not protect you against sexually transmitted infections. If you are worried about this, the condom will be a better option.
  • The IUD may be spontaneously expelled during your period, especially if the flow is heavy and usually occurs during the first few months
  • The insertion and removal must be performed by a medically trained staff member.
  • During insertion, there is a small risk of perforation of the uterine wall, and there may be bleeding and pain. It can be a serious complication that may require surgical intervention
  • There is a risk of infection during insertion. However, the risk is small and usually occurs within the first few weeks after insertion.
  • There may be changes in menstrual cycles – the hormonal IUD may cause irregular light bleeding or spotting, especially in the first few months. The copper IUD may cause menses to be heavier and painful.

It is important to discuss these effects with your healthcare provider to decide if this is a suitable option for you and will help you make an informed decision.

Who Can Use an IUD?

Most women can use an IUD safely. Prior to insertion, your healthcare provider will assess your suitability and discuss available options for you. IUD may not be suitable for you if you have the following conditions:

  • Current or suspected infection of the pelvis or vagina, especially sexually transmitted infections.
  • Unexplained vaginal bleeding
  • Abnormal uterus structure or fibroids that interfere with the placement of the IUD
  • Allergy to copper (for the copper IUD)
  • Previous ectopic pregnancy

What to expect during the insertion?

  • It is a relatively quick and straightforward procedure performed in the clinic.
  • Preparation: your healthcare provider will perform a pelvic exam to assess the position and size of your uterus. If there is the presence of abnormal discharge or suspected infections, the test may be done to exclude infections and the insertion deferred.
  • In some situations, oral painkiller medication may be given 30 minutes prior to insertion to reduce pain and discomfort.
  • The IUD is inserted through the cervix into the uterus using a special applicator. You may experience some cramping or discomfort during the procedure.
  • There is usually some spotting or cramping for a few days after insertion. For hormonal IUD, the spotting may persist a little longer and can be irregular for several weeks.
  • Over-the-counter pain relievers for a few days can help manage any discomfort.

Post insertion care

  • There is a short thread that hangs out of the cervix (usually 2 to 3 cm). You can feel for this thread regularly to ensure the IUD is still in place, although this is not really necessary.
  • Be aware of complications associated with IUD use and see your healthcare provider if you have – severe pain, abnormal vaginal discharge, heavy bleeding, fever, or any other unusual symptoms.
  • Attend the follow-up appointments, which is typically a few weeks after insertion, to check the IUD’s position and address any concerns.
  • The IUD can be seen easily in the uterus via an ultrasound scan.
  • You should take note of the removal date. The removal of the IUD is a simple procedure and is performed in the clinic.

You should consult your healthcare provider immediately if you have the following:

  • Inability to feel the IUD string, or if the string feels longer than usual
  • Severe abdominal or pelvic pain
  • Abnormal per vaginal bleeding – either heavy or prolonged
  • Fever or chills, which may suggest infection
  • Unusual vaginal discharge
  • Painful intercourse
  • Suspected pregnancy

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Adenomyosis – an update

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Adenomyosis is a benign uterine disease in which endometrial tissues (glands and stroma) are found within the myometrium (wall of the uterus). It has been described as endometriosis internal.

In a normal menstrual cycle, the endometrial tissue will grow, becomes thickened and then shed, resulting in the expected cyclical or monthly menstrual bleeding. If this happens in the uterine wall (myometrium), the resulting bleeding in the wall will cause pain. In the long term, the uterine wall will progressively thicken, thus producing a diffusely enlarged uterus. It often occurs along with other conditions that affect the pelvic organs, especially еոԁοmеtriosis. Αԁеոοmуoѕiѕ can also co-exist in people with fibroids, which are abnormal growths that form in the muscle of the uterus.

Causes

The cause of such growth in the uterine wall is not known. It may be related to repeated childbirths, pelvic endometriosis, increasing age and late childbirth. There is an increased association of pelvic endometriosis and adenomyosis in about 30% of cases. Other diagnosis commonly found in women with adenomyosis include fibroids and endometrial polyps.

Incidence

The exact incidence of the disease is unknown. It is generally estimated that 20% of women have adenomyosis. It is likely to be higher, due to the fact that many women are now delaying childbirth till a much later age.

This is a picture showing the uterine enlargement due to adenomyosis. The red patches represent the endometrial tissue, which bleeds during every menstrual cycle.

Clinical symptoms and signs

Some women with adenomyosis are asymptomatic and diagnosis is only made on histological examination of the uterus. Typical symptoms of adenomyosis are:

• Heavy menstrual bleeding – this is due to increased uterine cavity bleeding surface area as a result of enlargement and inadequate uterine contraction.
• Dysmenorrhea (menstrual or period pain) – the pain is usually severe and can be prolonged. The pain usually coincides with the timing of excessive menstrual flow. In some women, the pain may persist even after cessation of menses and present as chronic pelvic pain.
• Dyspareunia (painful sex) or frequency of urination—is due to the enlarged and tender uterus.
• Infertility: Women with adenomyosis have a higher incidence of infertility and miscarriage.
The examination may reveal:
• Tenderness in the lower abdomen during menses
• Enlarged uterus which is palpable per abdomen
• Anaemia due to excessive menstrual bleeding
• A uterus that is larger than normal (see diagram).

Diagnosis

The diagnosis of adenomyosis can only be confirmed via microscopic examination of the uterine specimen taken from the hysterectomy (after removal of the uterus). The diagnosis is often suspected from clinical history, examination, and imaging scans. An ultrasound scan of the pelvis will show mixed echogenicity in the uterine wall. The uterine wall is typically thickened and more commonly in the posterior wall. These findings may be confused with fibroids, and they may also co-exist. The more accurate imaging modality is Magnetic Resonance Imaging (MRI). It is more specific to the diagnosis and can differentiate adenomyosis from fibroids.

TREATMENT

The only definitive treatment for adenomyosis is total hysterectomy (removal of the uterus), with or without ovarian conservation. Some women may respond to medical therapy but eventually majority will need hysterectomy for cure. Therefore, early diagnosis is important because women with early adenomyosis respond better to medical therapies.

1. Medical therapies
• Tranexamic acids – this is given for reduction of heavy menstrual flow and to be taken at the start of menstrual bleeding for 2 to 4 days. It may help to relieve period pain as well if there is a reduction of menstrual flow.
• Painkillers – usually the non-steroidal anti-inflammatory drugs (NSAIDs) is the first choice such as mefenamic acid, diclofenac, ibuprofen and naproxen. For those who cannot tolerate it due to gastric side effects, COX-2 inhibitors such as celecoxib or etoricoxib tablets can be taken.

    • Birth control pills – combined oral birth control pills can be use if there is additional need for contraception. This can help in reduction of menstrual flow and period pain. It is best if taken continuously for several packs before a break (pill free interval). This extended regime will reduce the number of menstrual bleeds in a year.
    • Progestogens – this is a synthetic hormone that induces thinning and atrophy of the endometrial tissue and reduces menstrual flow. It can be given orally or as an injection every 3 months (marketed as Depo-Provera). The oral progestogen is to be taken daily and the available formulations are: norethisterone, dienogest (Visanne), medroxyprogesterone acetate, dydrogesterone. The side-effects most commonly seen with progestogen usage include troublesome breakthrough uterine bleeding, weight gain, abdominal bloating, oedema, acne and mood changes. Progestogens are commonly used for endometriosis but can be prescribed as empirical therapy to reduce or even stop menstrual flow in adenomyosis.
    • Intrauterine system (MIRENA) – Mirena is a hormonal intrauterine device (IUD) that releases a progestogen and can be used for contraception. The device is a T-shaped plastic frame that is inserted into the uterus and lasts for 5 years. The daily progestogen release will suppress or reduce menstrual bleeding and will help in improving pain and anaemia. However, Mirena will not be suitable for those who presented late with an enlarged uterus. The Mirena will not fit well in an enlarged uterine cavity and the response will be poor. Expulsion rate is also higher.
    Regular follow-up is required to assess response to therapy and to monitor the uterus size via clinical examination and ultrasound scan of the pelvis. Increasing pain and heavier menstrual flow with worsening anaemia suggest failure of medical therapies and is an indication for surgery.

    2. Uterine artery embolization (UAE) – has been offered in some centers for the treatment of symptomatic adenomyosis. It is a minimally invasive option to stop the main blood supply to the uterus. However, it is usually not done for women who might want to get pregnant. It is effective for those nearing perimenopausal age. For younger patients, there is a higher rate of symptom recurrence.

      3. Surgery – if the adenomyosis lesion is focal or localized, removal or burning of this abnormal area may be offered if keen for fertility or for uterus preservation. Ultimately, hysterectomy (removing the uterus) is often the best option for a cure. Oophorectomy (removal of the ovaries) at the same time is not required unless otherwise indicated.

      Disclaimer

      This is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. It is important for readers to seek proper medical advice when necessary.

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      Progestogen-only Injectable (POI) Contraception

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      Progestogen-only injectable contraception is a hormonal type of contraception that is given through an injection. It contains a synthetic form of the hormone progesterone, known as progestin or progestogen. They provide protection against pregnancy for up to 8 to 14 weeks.

      Types

      • Medroxyprogesterone acetate (DMPA)
      • Norethisterone enanthate (NET-EN)

      Mechanism of action

      • This hormone works primarily by suppressing ovulation (preventing the release of an egg from the ovaries).
      • It also thickens cervical mucus, making it more difficult for sperm to reach and fertilize an egg.
      • It can thin out the uterine lining, making it less suitable for the development of the fertilized egg.

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      Progestogen only pill (POPs)

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      This type of pill does not contain oestrogen and the dose of progestogen is significantly lower than in those used in combined oral contraceptive pills (COC). It is also called the “mini-pill” and is useful for women who do not want pills that contain oestrogen or in situations where the oestrogen is not suitable for medical reasons. They are a highly effective method of birth control when taken correctly.

      Formulation – Available formulations are:

      • Norethisterone 350 ug (NET) – (Noriday)
      • Levonorgestrel (LNG) 30 μg
      • Desogestrel (DSG) 75 μg – (Cerazette)

      Levonorgestrel (LNG) and norethisterone (NET) are grouped as “traditional’ POPs”

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      Admission for surgery – what to bring to the Hospital

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      This article will help you to prepare the essential items that you need to bring to the hospital for your admission. The list here is just a suggestion or a guide only, and you may make your own adjustment, based on your own preference. Decide which items you will need for a comfortable stay and recovery. However, you should not over-pack so as to inconvenience everyone, including yourself during your admission or discharge. The items will also depend on the expected length of stay in the hospital.

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      Bartholin glands disorders (Bartholin cyst / Bartholin abscess)

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      The Bartholin gland is located on either side of the vaginal opening, on the inner aspect at about 5 and 7 o’clock position. The glands secrete a fluid (mucus) that keeps the vagina moist and helps lubricate the vaginal area during sexual activity. The gland is not visible or palpable unless it is swollen.

      Common disorders of the Bartholin glands are:

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      Home Pregnancy Tests

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      The currently used method to confirm pregnancy depends on the detection of the hormone human chorionic gonadotropin (hCG), which is present in the blood and urine of a pregnant woman. The hCG hormone is produced by the placenta in increasing amounts within 10 days after fertilization. The home pregnancy test kit detects this hormone in the urine of the pregnant woman.

      An absence of a menstrual period in a sexually active female is usually the first reason to do a pregnancy test. Many women may experience some symptoms and signs of pregnancy as early as 5 to 6 weeks after the first day of their last menstrual period, provided she has a regular menstrual cycle.  These may include:

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      Cervical Polyps

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      A cervical polyp is a benign fleshy growth on the cervix. The cervix is the part of the uterus that is visible during the speculum examination. It is also called the neck of the uterus. Cervical polyp arises from cells, either from the cervical canal (this type is also called an endocervical polyp) or from the outer surface of the cervix.

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