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.

Incidence

Up to 4% of women have cervical polyps.

Cause

The exact cause is usually unknown. It can arise from any chronic inflammation of the cervix.

Symptoms and signsmenstrual bleeding

  • most women with polyps have no symptoms and only diagnose during routine cervical cancer screening.
  • it can cause abnormal vaginal bleeding and usually presents as prolonged menstrual spotting, intermenstrual bleeding, or bleeding after sex.
  • it may present as abnormal vaginal discharge.

Treatment

  • polyps can be easily seen during a speculum examination and removed in the clinic. A speculum is an instrument that is inserted into the vagina to open the walls and visualized the vagina and cervix.
  • the procedure to remove the polyp is called a polypectomy. It is a relatively quick and painless procedure, using a pair of forceps. If the polyp is large, then the removal may need to be done in the operating theatre and under anaesthesia.
  • post polypectomy care – there may be mild cramping after polyp removal. Most women may have light bleeding soon after. Painkillers can be taken if the pain is significant (such as paracetamol, mefenamic acid, ibuprufen or celecoxib). Sexual activity should be avoided for a few days. Avoid the use of tampons till the bleeding stops. Most women can resume their usual activities within a day or two after getting a polyp removed.
  • the cervical polyp can recur. However, it is not common and you should not be worried about it as long as you continue to see your doctor for the recommended cervical cancer screening interval.

Complications

Complications are rare. It can be due to the:

  • Polyps – infection, abnormal excessive bleeding, increasing in size, possible pre-cancerous or cancerous change.
  • Procedure (polypectomy) – pain, excessive bleeding, infection

See your healthcare provider if you develop:

  • Abnormal vaginal bleeding – prolonged or excessive.
  • Lower abdominal or vagina pain.
  • Abnormal vaginal discharge.
  • Symptoms suggestive of infection – unwell, fever, body ache, abnormal vaginal discharge

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Dysmenorrhea (period pain / menstrual cramps / menstrual pain)

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Dysmenorrhea refers to lower abdominal pain felt during menstruation. It is divided into two broad categories, which are primary and secondary dysmenorrhoea.

  1. Primary dysmenorrhea refers to the presence of pain during menses without any obvious gynaecological disease that could account for these symptoms. The pain is typically recurrent, crampy pain that starts just before or with the onset of menses and then gradually reduces over the next 24 to 72 hours. It is more often seen in adolescents and young females. Physical examination and an ultrasound scan of the pelvis is usually normal.
  2. Secondary dysmenorrhea refers to the pain before and/or during menstruation in females with a gynaecological disease that could explain the symptoms. These could be endometriosis, adenomyosis, or uterine fibroids. The cramping pain can be in the lower abdomen, lower back or radiates to the inner thighs. The pain may even persist after menstruation has stopped.

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Infertility treatment

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Treatment for infertility will depend on the underlying cause. Unfortunately, not all causes can be treated by surgery, medications, or both. Even if the suspected underlying cause of infertility has been treated, not all women will conceive. In about 10% to 15% of infertile couples, the cause is usually not found after a standard clinical and laboratory evaluation. This is term as unexplained infertility. Deciding what to do, if anything, when a fertility evaluation is completed may not be easy. Any treatment for conceiving is actually “maximizing fertility potential” rather than “curing infertility.” There is no guarantee that any of them will result in the successful birth of a baby. Ultimately, if conventional therapies do not achieve the desired pregnancy, then the last resort will be assisted reproductive technology (ART). This refers to procedures such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

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Infertility investigations

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The woman and her partner should be present at the initial evaluation for infertility. The doctor will obtain a full clinical history from the couple and then proceed on to a physical examination. The initial investigations that need to be performed will be based on these assessments. Sometimes, the cause of the infertility may be found at this visit. Further evaluation and clinic visits may be necessary for other couples. It may take several weeks. This is because some of the tests may have to be repeated for verification at different specific times in her menstrual cycle. The initial workup of a man usually can be done faster, because men have no monthly cycles and because there are fewer tests for men.

COMMON INVESTIGATIONS IN FEMALE

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Stress and hormonal imbalance in women

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Life is full of stress. It is common to everyone. Some people are able to handle stress better than others while many cannot cope with the stress that comes with everyday modern living. Stress can affect the well-being of both one’s physical and mental health. Physical stress occurs when a person does not have enough rest, engaging in exercises to the extreme limit of bodily endurance, has a poor diet, or suffers from illness and disease. Mental stress may arise from worries about matters such as money, jobs, retirement, marriage, or the death of loved ones. Sometimes the stress that arises is subtle, and a person may not even realize she is experiencing it. For example, one may feel tired and overwhelmed after a hard day’s work. This fatigue may be a result of either physical or mental stress or a combination of both. Either way, the body is taxed to some degree.

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Premenstrual Syndrome (PMS)

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Premenstrual syndrome (PMS) involves symptoms that begin 7 to 14 days prior to the next menses and usually disappear when men­struation flow begins. A significant proportion of women experience PMS at some point in time; some more frequent than others. The severity can range from mild only to very severe form. Luckily, this is only seen in a small proportion of women. For some women, it may get worse as they age and will disappear once they reach menopause. However, during this transition period, it may overlap with the menopause symptoms.

 Symptoms and signs

  •  Physical changes such as fatigue, lack of energy, tender and/or swollen breasts, fluid retention causing puffiness in ankles, hands, and face.
  • Dizziness or fainting, headaches.
  • Digestive issues such as constipation, diarrhoea, bloating, heartburn, food cravings, increased appetite or overeating.
  • Psychological symptoms – such as mood changes, pronounced tension, and anxiety, sleeping difficulty, depression, difficulty concentrating, less interest in work or the usual activities.
  • Skin changes such as acne outbreaks.
  • Sexual issues.

These are the common ones and there are many other symptoms that may be attributed to PMS as well. If you think you have PMS, you should keep track of your symptoms and assess the severity for at least 2 months. The use of the PMS symptoms diary is very useful and you can show this diary to the doctor during the consultation. It is a useful aid for the diagnosis and for assessment of response to treatment. You can download one example from this link.

Causes

 The cause is unknown but may be due to fluctuations in the circulating level of hormones in the regular menstrual cycles (especially oestrogen and progesterone). These fluctuations cause retention of sodium in the blood­stream, resulting in oedema in body tissues and contributing to some of the physical symptoms. There may be other contributing factors such as psychiatric, endocrinologic, diet, and changes in the chemical’s levels in the body (endorphin, sero­tonin, prostaglandin).

Risk increases with:

  • Increased levels of stress.
  • Caffeine and high fluid intake seem to worsen symptoms.
  • Smoking may also intensify or increase symptoms.
  • PMS increases with age.
  • PMS can occur with other disorders such as depression.

Diagnosis

A physical examination and other investigations will be done to rule out other disorders. Diagnosis usually depends on a history of symptoms and their relationship to the menstrual cycle. Keeping a menstrual diary to monitor and record symptoms severity is helpful. This is also essential for diagnosis and assessment of improvement to treatment.

Prevention

No specific preventive measures but you can try to avoid stressful situ­ations at the expected time of PMS. Support from close friends or spouse will be helpful.

Expected outcome

Lifestyles and behavioural modifications, with or without medications can adequately control PMS symptoms.

Complications

Physical and psychological symptoms may be severe enough to disrupt a woman’s life.

Treatment

General

  • Treatment steps involve education and understanding of the problem faced by the woman. Begin a regular, aerobic exercise program (such as walking, biking, swimming etc) and learn relaxation techniques. These are beneficial in general and both are encouraged as part of stress reduction. Meditation or yoga may be helpful. If feasible, reduce activities during symptomatic days if it helps.
  • Stop smoking.
  • Get regular sleep.
  • Cognitive behavioural therapy (CBT) may provide some relief for some women. This can be done concurrently with other therapy for more effective relief of PMS.

Dietary changes

  • Decrease salt intake during the premenstrual phase.
  • Eat a balanced diet with plenty of fiber (fruits and vegetables), whole grains varieties, and food rich in calcium and vitamins B.
  • Eat regular meals and snacks throughout the day. Skipping a meal may make you more miserable due to low blood sugar or hungry pang.
  • Limit or abstain intake of alcohol, caffeine, and sodas.
  • Keep well hydrated

Medications

These are used with varying degrees of success. Treatment should be individualized, based on the main presenting symptoms and the woman’s reproductive needs at that point in time.

  • Complementary medicine such as Vitex agnus castus (chasteberry) can be tried in mild PMS and can be effective in some women. There are also many vitamins and supplements that are popular as a treatment for PMS such as primrose oil (for breast tenderness), vitamin B6, calcium and vitamin D. These may be helpful in relieving a few symptoms but may not work for everyone. It is generally not prescribed as a routine. If you are taking any complementary medicine or supplements, please inform your doctor about it because some of these may interact with the prescribed medications. The role of acupuncture is still uncertain.
  • Diuretics pills can help you to pass out more urine to reduce fluid retention.
  • Pain medications such as paracetamol, ibuprofen or celecoxib.
  • Medications are used to suppress the cyclical hormonal change and these include the combined oral contraceptive pills (COCs) and gonadotropin-releasing hormone agonists (GnRH agonist). COCs pills will be a good option for those who require contraception as well. Drospirenone-containing COCs are effective and licensed to be used for PMS. GnRH agonist injection will suppress the ovarian hormone production, leading to a state of low oestrogen or pseudo-menopausal state. However, for long term use, the oestrogen-progestin combinations pills need to be given as add-back therapy to avoid menopausal symptoms and estrogen-deficiency complications such as bone loss
  • Selective serotonin reuptake inhibitors (SSRIs) are a group of drugs that target the serotonin system by increasing the level in the brain. Serotonin is one of the chemicals that is important in the transmission of signals between brain nerve cells (neurons). Elevated levels will improve the transmission of signals among the neurons in the brain and help to improve mood and sense of well-being.

Surgery

Surgery is the last resort. This is rarely required because generally, medical therapy is usually effective in relieving symptoms of PMS. This type of surgery is a major operation and will involve the removal of both ovaries and the fallopian tube, usually in conjunction with the removal of the uterus (hysterectomy).

You should see your doctor immediately if you have:

  •  You or a family member has symptoms of PMS that interfere with normal activities or relationships.
  • Symptoms do not improve, despite treatment.
  • New or unexplained symptoms develop. Medications used in treatment may produce additional new side effects.

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Bacterial vaginosis (BV)

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Bacterial vaginosis (BV) is caused by an overgrowth of certain types of bacteria, which results in vaginal inflammation.  With BV, there is a shift in the bacterial ecosystem, favouring the “not so good or healthy” type such as Gardnerella vaginalis, Mycoplasma hominis and Mobiluncus species and a corresponding reduction in the healthy types such as lactobacillus. There is also a disturbance of the vaginal pH. Bacterial vaginosis most often occurs during reproductive years. It is not regarded as a sexually transmitted infection, but sexual activity has been linked to the development of this infection.

Symptoms and signs

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Myths and facts of combined oral contraceptive (COC) pills

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Currently, there is a wide selection of contraceptive methods available to suit the various reproductive needs of couples. Despite these, there is still a huge unmet need with regards to contraception. There are 123 million women around the world who are not receptive to contraception. In the 2015 United Nations Population Fund (UNFPA) report, 15 million adolescent girls in developing countries gave birth and 13 million lacked access to contraceptives. WHO estimated that approximately 214 million women of reproductive age, in developing regions, who want to avoid pregnancy are not using a modern contraceptive method and between 2015 and 2019, almost half of all pregnancies were unintended.

The combined oral contraceptive (COC) pills are readily available in the markets and yet women avoid them due to their belief in the myths surrounding them. Following are some common myths regarding the combined oral contraception pills and the facts to dispel them.

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