Gynecology In Indore

Reproductive issues/Infertility

Know about Infertility and its Treatment

Being a mother is something many women dream of but some women find it extremely difficult to live this dream. A couple is said to be infertile if they are unable to conceive in 12 months or more of well-timed unprotected intercourse. The risk of infertility increases with age. Infertility can affect both men and women  and can be triggered by a number of factors

The risk factors for infertility are-

1. increasing age of couple, more than 35 for female and more than 40 for male. Although fertility starts declining after 30 years in Indian woman.
2. Obesity
3. being extremely underweight,
4. smoking and alcohol consumption.
5. In addition, a diet that is deficient in zinc, folic acid and vitamin  B12 can aggravate problems with conception.
6. Ovulation and sperm production may also be affected by stress and exposure to chemicals, pesticides, Diabetes, heart disease, certain drugs etc

Thankfully, in most cases, infertility is not a condition one has to live with and with the latest technology most of the couple can fulfil there dream of having a baby.

•  Infertility can be caused by the following:
• Sperm disorders (≥ 35% of couples)
• Ovulatory dysfunction or decreased ovarian reserve (about 20%)
• Tubal dysfunction and pelvic lesions (about 30%)
• Abnormal cervical mucus (≤ 5%)
• Unidentified factors (about 10%)
• Inability to conceive often leads to feelings of frustration, anger, guilt, resentment, and inadequacy.

Treatment for infertility depends on the factors triggering infertility. Hence, the first step to deal with infertility is to understand the factors that cause this condition.

Most common causes of infertility include:

1. Anovulation : Anovulation refers to the absence of ovulation. This condition is often caused by the polycystic ovarian syndrome. If an egg is not released by the ovaries, it cannot be fertilized by sperm and hence causes difficulties with conception/li>
2. Tubal infertility: A blocked fallopian tube or scarring on the fallopian tube can by caused by pelvic inflammatory disease, STDS or endometriosis.
3. Male factor: Sperm may be too few in number ( Oligospermia), move too slowly (Asthanosperia0, or be structurally abnormal (Teratozoospermia)l, or their passage out of the body may be blocked or disrupted.

Diagnosis and Investigations in a case of infertile couples

A doctor’s evaluation

Various tests depending on the suspected cause

The diagnosis of infertility problems requires a thorough assessment of both partners. Usually, the assessment is done after at least 1 year of trying to achieve a pregnancy. However, it is done sooner if-

• The woman is over 35 (usually after 6 months of trying to become pregnant).
• The woman’s menstrual periods occur infrequently (fewer than nine times a year).
• The woman has a previously identified abnormality of the uterus, fallopian tubes, or ovaries.
• Doctors have identified or suspect problems with sperm in the man.
• Age is a factor, especially for women. As women age, becoming pregnant becomes more difficult, and the risk of complications during pregnancy increases. Also, women, particularly after age 35, have a limited time to resolve infertility problems before menopause.

Tests are done depending on the suspected cause. Basic tests done are

• TSH for thyroid disorders
• Serum Prolactin levels, Increased levels may lead to ovulatory disfunction.
• For problems with ovulation: Ultrasonography to determine whether and when ovulation occurs.
• For tubal factor- HSG ( Hysterosalpingography)- HSG, is an X-ray test to outline the internal shape of the uterus and show whether the fallopian tubes are blocked. In HSG, a thin tube is threaded through the vagina and cervix. A substance known as contrast material is injected into the uterus.
• Chromopertubation-  Chromopertubation is a method for the study of patency of fallopian tube in suspected infertility in women. This is done through Laparoscopy.
• For sperm disorders: Semen analysis

Fertility treatment includes:

1. Ovulation induction: This involves stimulating ovaries in women suffering from anovulation and infertility with the help of medication. This can also be used to treat infertility caused by the polycystic ovarian syndrome. Ovulation can be induced with oral and injectable medication. The success of this form of treatment depends on the age of the woman, cause and the type of medication used.
2. Artificial insemination:Intrauterine insemination can be used to treat unexplained infertility, early stages of Endometriosis, hostile cervical condition, including cervical mucus problems and ejaculation dysfunction in males. The age of the woman plays a significant role in determining the success of this form of treatment. Intrauterine insemination may be accompanied by the use of oral or injectable medication to stimulate ovaries
3. In Vitro Fertilization (IVF) or Inracytoplasmic sperm injection  (ICSI) :   Main indication of  IVF is damaged or bilateral blockage of Fallopian tubes. This process involves stimulating Ovaries for developing multiple eggs which are then retrieved and fertilized in a laboratory and then  embryos are transferred back into the uterus. IVF can be used to treat almost all forms of infertility except those caused by severe anatomic problems with the uterus and has a high success rate.

Adolescent Counseling

Adolescence is a period that begins with puberty and ends with the transition to adulthood (approximately ages 10–20). During this period of maturation, a person goes through various physical, psychological, social, identity and relationship changes.žOnein five individuals in the world today is an • This is the most important period in one’s life as it giveslast chance to correct the growth lag and malnutrition.

adolescent (around 1.2 billion).>

Biological changes or Puberty-

• Growth spurt or Increase in height>
• Breast development
• Hair growth in underarms and private parts
• Menstruation

Other changes are-

• Develop their own identity
• Acquire logical reasoning
• Enjoy the company of peers.
• Mood swings and show strong feelings and emotions.
• Relationships and intimacy with opposite sex.
• Risk taking behaviours

Adolescent issues

1. Menstrual problems like irregular menses, excessive prolonged bleeding, amenorrhoea, dysmenorrhoea etc
2. Vaginal infections, STDs and other infection
3. Anemia and Nutritional deficiencies
4. PCOD – Obesity & overweight
5. Ignorance about sex and sexuality, unsafe sex
6. Vaccinations
7. Sexual abuse
8. Ignorance about contraception
9. Adolescent pregnancy
10. Emotional & Behavioral problem
11. Substance abuse like smoking, alcohol & drugs
12. Identity problems.
    Adolescent issues will be depth in a separate page

What is Polycystic ovarian syndrome (PCOS)?

Polycystic ovary syndrome (PCOS) is a hormonal disorder with over production of male harmone (Androgen) and insulin resistance (Insulin resistance is a condition in which the body produces insulin but does not use it effectively which again lead to hormonal imbalance) that causes varieties of symptoms like irregular menstrual periods, overweight ,obesity, hirsuitism (excessive hair growth all over body), acne etc.

Incidence-The condition occurs in about 5 to 10 percent of female population of developed countries .Much higher incidence is reported in india 3.7 to 22.5% and In Indian adolescents it is 9.13 to 36%.

Cause of PCOD– The cause of polycystic ovary syndrome (PCOS) is not fully understood, but genetics may be a factor. PCOS can be passed down from either your mother’s or father’s side. PCOS problems are caused by hormonal changes. One hormone change triggers another, which changes another.

How PCOS patients presents-

• Menstrual irregularities is the commonest problem PCOD patients present with. This can be in the form of scanty menses, prolonged menstrual cycles, prolonged and heavy menses or absent menses.
• Weight gain and obesity– Because of hormonal imbalances most women gradually gain weight. There are few women or adolescents who do not gain weight. They are known as Lean PCOS.
• Male-pattern hair growth (hirsutism is the excessive growth of thick, dark terminal hair in women where hair growth is normally absent) may be seen on the upper lip, chin, neck, sideburn area, chest, upper or lower abdomen, upper arm, and inner thigh.
• Pimples- ( Acne) is a skin condition that causes oily skin and blockages in hair follicles .Mostly occurs on face, but sometimes may be seen on back and upper chest.
• Infertility– Many women with PCOS do not ovulate regularly, and it may take these women longer to become pregnant. An infertility evaluation is often recommended after 6 to 12 months of trying to become pregnant.
•  Metabolic syndrome– Many patients with polycystic ovary syndrome (PCOS) also have features of the metabolic syndrome, including insulin resistance, Diabetes, obesity, and dyslipidemia (abnormal Lipid profile),  suggesting an increased risk for cardiovascular disease(CVD).

Risk Factors for PCOS

• Early or late Menarche- age of first menses.
• Obesity.
• Family History of PCOS ,irregular periods or Diabetes.
• Sedentary and improper life style.

Long term sequel of PCOD-

• They are at high risk of developing Diabetes.
• High blood pressure, high cholesterol and heart diseases.
• Obesity.
• High risk of developing uterine cancer (endometrial cancer) due to unopposed action of Oestrogen harmone.
• Thyroid Disorders( Hypothyroidism)
• Sleep apnea — Sleep apnea is a condition that causes brief spells where breathing stops (apnea) during sleep. Patients with this problem often experience fatigue and daytime sleepiness.>
•  Depression and Anxiety.

PCOS DIAGNOSIS

When a patient goes to a doctor with any of the above mentioned symptoms then the doctor takes full history, asks for other symptoms and examines  thoroughly and then may advise certain tests to confirm the diagnosis.

There is no single test for diagnosing polycystic ovary syndrome (PCOS). One may be diagnosed with PCOS based upon symptoms, blood tests, and a physical examination. Expert groups have determined that a woman must have two out of three ( Rotterdam criteria ) of the following to be diagnosed with PCOS:

• Irregular menstrual periods caused by anovulation or irregular ovulation.
• Evidence of elevated male hormone (Testosterone) levels. The evidence can be based upon signs (excess hair growth, acne, or male-pattern balding) .
• Polycystic ovaries on pelvic ultrasound.- it shows enlarged ovary with multiple cysts. This is seen in almost 30% of cases.

Investigations-In women with moderate to severe hirsutism (excess hair growth), blood tests for testosterone and In dehydroepiandrosterone sulfate (DHEA-S) may be recommended.

• TSH and Prolactin hormones should also be done as Hypothyroidism and or Hyperprolactinemia  may be associated with PCOS.
• If PCOS is confirmed, blood glucose and cholesterol testing are usually performed.
• An oral glucose tolerance test is the best way to diagnose pre diabetes and/or diabetes.

Adolescent PCOS

In adolescents, presence of oligomenorrhea (scanty menses) or amenorrhea (absent menses) beyond two years of menarche should be considered an early clinical sign of PCOS, followed by (Rotterdam criteria ) of adults for diagnosis of PCOS as mentioned above.

For diagnosis of PCOS in adolescents should include 5 tests-

•   Serum total testosterone (cut off 60 ng/dL)
•  Fasting serum Insulin level
•  Oral glucose tolerance test (OGTT) zero, two hours after 75 gm glucose load.
•  Serum 17– hydroxyprogesterone (assessed at 8 am)
•  Serum TSH Serum and
•  prolactin levels

MANAGEMENT OF PATIENTS WITH PCOS

Both pharmacological and non-pharmacological management strategies are crucial in the overall management of PCOS. Usually treatment depends upon the symptoms for which the patient comes. As PCOS can not be cured permanently but can be managed well. long term treatment plan should be given to manage her bothersome symptoms and also to prevent long term sequelae.

Treatment-

Lifestyle modification forms the mainstay of treatment. This includes-

• Physical activity- In adults and adolescents with PCOS, daily strict physical activity sessions for at least 30min/day or 150min/ week are recommended.
• Weight loss — Weight loss is one of the most effective approaches for managing insulin abnormalities, irregular menstrual periods, and other symptoms of PCOS. For example, many overweight women with PCOS who lose 5 to 10 percent of their body weight notice that their periods become more regular. Weight loss can often be achieved with a program of diet and exercise.>
• Diet – it is recommended to follow calorie restricted diet (low carbohydrate and fat, high protein diet)

Weight loss surgery may be an option for severely obese women with PCOS. Women can lose significant amounts of weight after surgery, which can restore normal menstrual cycles, reduce high androgen levels and hirsutism, and reduce the risk of type 2 diabetes.

Oral contraceptives — Oral contraceptives (OCs; with combined estrogen and progestin) are the most commonly used treatment for regulating menstrual periods in women with polycystic ovary syndrome (PCOS). OCs protect the woman from endometrial (uterine) hyperplasia or cancer by inducing a monthly menstrual period. OCs are also effective for treating hirsutism and acne.

Women with PCOS occasionally ovulate, and oral contraceptives are useful in providing protection from pregnancy. Although an OC allows for bleeding once per month, this does not mean that the PCOS is “cured;” irregular cycles generally return when the OC is stopped. Oral contraceptives decrease the body’s production of male hormones( androgens).

Anti-androgen drugs (such as spironolactone) decrease the effect of androgens. These treatments can be used in combination to reduce and slow hair growth. Oral contraceptives and anti-androgens can also reduce acne.

Metformin — Metformin is used to decrease insulin resistance in these patients. It improves the effectiveness of insulin produced by the body. It was developed as a treatment for type 2 diabetes but may be recommended for women with PCOS with obesity and insulin resistance.

If a woman does not have regular menstrual cycles, the first-line treatment is a hormonal method of birth control, such as birth control pills. If the woman cannot take birth control pills, one alternative is to take metformin; a progestin is usually recommended periodically to have withdrawal bleeding in addition to metformin, for six months or until menstrual cycles are regular.

Metformin may help with weight loss. Although metformin is not a weight-loss drug, some studies have shown that women with PCOS who are on a low-calorie diet lose more weight when metformin is added. If metformin is used, it is essential that diet and exercise are also part of the recommended regimen because the weight that is lost in the early phase of metformin treatment may be regained over time.
Treatment of infertility

In PCOS lack of ovulation is the cause of infertility, The primary treatment for women who are unable to become pregnant, is weight lossh. Even a modest amount of weight loss may allow the woman to begin ovulating normally. In addition, weight loss can improve the effectiveness of other infertility treatments.

Ovulation inducing drugs (like clomiphene, Letrozole etc)  are also used in conjunction with Matformin. Your doctor will discuss it with you.

Prevention-  PCOS cannot be prevented fully but early diagnosis and management helps prevent long-term complications, such as infertility, metabolic syndrome, obesity, diabetes, and heart disease.

Vaginal Infections

Normal Vaginal Discharge  

Normal vaginal discharge is usually clear or milky and may have a subtle scent that is not unpleasant or foul smelling. It’s also important to know that vaginal discharge changes over the course of a woman’s menstrual cycle. These changes in color and thickness are associated with Hormonal changes and ovulation and are natural. This discharge provides moisture to the vagina thereby protects from vaginal dryness. Lactobacilli which are also known as good bacteria, prevents vagina from harmful infections like yeast infection, bacterial vaginosis etc. Vaginal discharge increases near ovulation, during intercourse or when sexually excited or in  vaginal infections

Any change in the vagina’s balance of normal bacteria can affect the smell, color, or discharge texture. These are a few of the things that can upset that balance:

Abnormal Vaginal Discharge- Most common causes are-

• Vaginal infections like yeast infection, bacterial vaginosis and    Trichomoniasis.
• STDS (sexually transmitted diseases
• Antibiotic or Steroid use
• Pelvic inflammatory disease (PID)

Yeast infection or Vaginal Candidiasis- A vaginal yeast infection is a fungal infection that causes irritation, Curdy discharge and intense itchiness of the vagina and the vulva (the tissues at the vaginal opening). This infection is also known as vaginal candidiasis, vaginal yeast infection affects up to 3 out of 4 women at some point in their lifetime.

Bacterial vaginosis-Bacterial vaginosis is a type of vaginal inflammation caused by the overgrowth of bacteria naturally found in the vagina, which upsets the natural balance. Women in their reproductive years are most likely to get bacterial vaginosis, but it can affect women of any age.

Symptoms include:

• Thin, gray, white or green vaginal discharge, Foul-smelling “fishy” vaginal odor, Vaginal itching, Burning during urination.
• Trichomoniasis (or “trich”) is a very common sexually transmitted disease (STD). It is caused by infection with a protozoan parasite called Trichomonas vaginalis.
• T vaginalis infection has strongly associated with the presence of other STIs (gonorrhea, chlamydia, and sexually transmitted viruses such as HIV)
• Trichomoniasis causes a foul-smelling vaginal discharge, genital itching and painful urination in women. Men typically have no symptoms. Complications include a risk of premature delivery for pregnant women.

providers should provide appropriate counseling, testing, and treatment for such infections.

Prevention and precautions –

• Personal hygiene- keep private parts clean and dry.
• While cleaning clean from front to back, If cleaned from back to front, it may carry bacteria from the potty area and give rise to infection.
• If infection is detected then both partners should be treated.
• Use a barrier method or condoms if any one of them is suffering from infection.
• Avoid using feminine products like deodorant or spays.
• Use cotton undergarments.
• Avoid jeans and wear loose underpants for proper flow of air.
• Avoid holding urine for a long time.
• Go for urination after intercourse.
• Take a full course of treatment.
• Avoid using Tampons during infection.

Urinary Tract Infection

This infection is very common in females because they have a shorter urethra than men and bacteria do not have to travel very far to reach and infect a woman’s bladder. This infection is mostly caused by E coli bacteria which usually comes from the potty area or anus.

A urinary tract infection (UTI) is an infection in any part of your urinary system — your kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract — the bladder and the urethra. Women are at greater risk of developing a UTI than are men.A strong, persistent urge to urinate.

• Symptoms of Urinary Tract Infection-
• A burning sensation when urinating.
• Passing frequent, small amounts of urine.
• Urine that appears cloudy.
• Urine that appears red, bright pink or cola-colored — a sign of blood in the urine.
• Strong-smelling urine.
• Abdominal pain – suprapubic, bilateral flanks, pelvic pain (females), perineal pain.

Risk Factors-

• Women – sexually active,
• postmenopausal
• Pregnancy
• Immunocompromised state – Diabetes Mellitus, Post-transplant, Age > 60 years, patient on steroids or any other immunosuppressive drugs
• Pregnancy
• Structural or Functional abnormalities of the Urinary tract – Vesicoureteric reflux, calculus in the urinary tract, urethral stricture etc

Prevention- Following steps can reduce risk of Urinary tract infection-

• Drink plenty of liquids, especially water
• Drink cranberry juice
• Maintain personal hygiene and cleanliness
• Do not hold urine for long periods of time
• Avoid the use of diaphragms, non lubricated spermicidal condoms for birth control,
• Dirty public toilets and swimming pools.
• If you have this infection then visit a health professional and get proper treatment. If you do not take complete treatment then it may recur again and again and may.

Complications of a UTI may include:

• Recurrent infections, especially in women who experience two or more UTIs in a six-month period or four or more within a year.
• If you don’t treat a UTI, a long-lasting kidney infection can hurt your kidneys forever. It can affect the way your kidneys function and lead to kidney scars, high blood pressure, and other issues.

 Always visit your doctor if you have the above mentioned symptoms.

The menstrual cycle is regulated by the complex interaction of hormones: luteinizing hormone, follicle-stimulating hormone, and the female sex hormones estrogen and progesterone.

The menstrual cycle has three phases:

• Follicular (before the release of the egg
• Ovulatory (egg release)
• Luteal (after egg release)

The menstrual cycle begins with menstrual bleeding (menstruation), which marks the first day of the follicular phase.

Menstruation 

When the follicular phase begins, levels of estrogen and progesterone are low. As a result, the top layers of the thickened lining of the uterus (endometrium) break down and are shed, and menstrual bleeding occurs.

Follicular phase –

About this time, the follicle-stimulating hormone level increases slightly, stimulating the development of several follicles in the ovaries. Each follicle contains an egg. Later in this phase, as the follicle-stimulating hormone level decreases, only one follicle continues to develop. This follicle produces estrogen.

Ovulatory phase

This begins with a surge in luteinizing hormone and follicle-stimulating hormone levels. Luteinizing hormone stimulates egg release (ovulation), which usually occurs 16 to 32 hours after the surge begins. The estrogen level peaks during the surge, and the progesterone level starts to increase.

Luteal phase

luteinizing hormone and follicle-stimulating hormone levels decrease. The ruptured follicle closes after releasing the egg and forms a corpus luteum, which produces progesterone. Progesterone and estrogen cause the lining of the uterus to thicken more, to prepare for possible fertilization. If the egg is not fertilized, the corpus luteum degenerates and no longer produces progesterone, the estrogen level decreases, the top layers of the lining break down and are shed, and menstrual bleeding occurs (the start of a new menstrual cycle).

Length of Menstrual cycle –

It varies from individual to individual from 21 days to 45 days.

 Menstrual disorders include:

• Abnormal uterine bleeding
• Absence of menstrual periods (amenorrhea)
• Menstrual cramps (dysmenorrhea)
• Premenstrual syndrome (PMS)

Bleeding from the vagina that occurs frequently or irregularly or lasts longer or is heavier than normal menstrual periods.

Causes of Abnormal menstrual bleeding

• Problems with ovulation –  The most common type of abnormal bleeding results from changes in the hormonal control of menstruation that cause problems with the release of the egg (ovulation). This type is called abnormal uterine bleeding due to ovulatory dysfunction.
• Fibroids and polyps
• A condition in which the endometrium grows into the wall of the uterus known as Adenomyosis.
• Bleeding disorders
• Problems linked to some birth control methods, such as an intrauterine device (IUD) or birth control pills
• Miscarriage
• Ectopic pregnancy
• Certain types of cancer, such as cancer of the uterus, and Cancer cervix

Diagnosis-

 Based on your symptoms and your age, along with symptoms and physical examination other tests may be needed. 

Ultrasound exam—

Sound waves are used to make a picture of the pelvic organs.

Hysteroscopy— A thin, lighted scope is inserted through the vagina and the opening of the cervix. It allows your ob-gyn or other health care professional to see the inside of the uterus.

Endometrial biopsy— A sample of the endometrium is removed and looked at under a microscope.

Sonohysterography— Fluid is placed in the uterus through a thin tube while ultrasound images are made of the inside of the uterus.

Magnetic resonance imaging (MRI)—  Rarely MRI or CT scan may be needed to make a diagnosis.

Management and Treatment- 

Medical Treatment-

• Hormonal birth control methods—Birth control pills, the skin patch, and the vaginal ring contain hormones. These hormones can lighten menstrual flow. They also help make periods more regular.
• Tranexamic acid—This medication treats heavy menstrual bleeding.
• Nonsteroidal anti-inflammatory drugs—These drugs, which include ibuprofen, may help control heavy bleeding and relieve menstrual cramps.

Surgical treatment-

If medication does not reduce your bleeding, a surgical procedure may be needed. There are different types of surgery depending on your condition, your age, and whether you want to have more children.

• Endometrial ablation destroys the lining of the uterus. It stops or reduces the total amount of bleeding. Pregnancy is not likely after ablation, but it can happen. If it does, the risk of serious complications, including life-threatening bleeding, is greatly increased. If you have this procedure, you will need to use birth control until after menopause.
• Uterine artery embolization is a procedure used to treat fibroids. This procedure blocks the blood vessels to the uterus, which in turn stops the blood flow that fibroids need to grow.
•  Myomectomy,surgical procedure in which Fibroids are removed but not the uterus.
•  Hysterectomy, the surgical removal of the uterus, is used to treat some conditions or when other treatments have failed. Hysterectomy also is used to treat endometrial cancer. After the uterus is removed, a woman can no longer get pregnant and will no longer have periods.

Absence of menstrual periods (amenorrhea) –

Having no menstrual periods is called amenorrhea. It is divided into Primary and secondary.

Primary amenorrhoea is defined as-

• Absence of start of menses or Menarche by age 16 years in presence of normal Pubertal development.
• Absence of start of menses or Menarche by age 14 years in absence of normal Pubertal development
• Absence of start of menses or Menarche 2 years after compilation of sexual maturation.

Secondary Amenorrhoea is defined as- 

Absence of menstruation for at least 6 months in females who have already established menstruation.

Amenorrhea is normal in the following circumstances:

• Before puberty
• During pregnancy
• While breastfeeding
• After menopause
• At other times, it may be the first symptom of a serious disorder.

Amenorrhea may be accompanied by other symptoms, depending on the cause.  For example, women may develop masculine characteristics (virilization), such as excess body hair (hirsutism), a deepened voice, and increased muscle size. They may have headaches, vision problems, or a decreased sex drive. They may have difficulty becoming pregnan

Common causes of primary amenorrhea include:

• A chromosomal or genetic problem with the ovaries (the female sex organs that hold the eggs).
• Hormonal issues stemming from problems with the hypothalamus or the pituitary gland
•  Structural problems with the reproductive organs, such as missing parts of the reproductive system.

Common causes of secondary amenorrhea include:

• Pregnancy (which is the most common cause of secondary amenorrhea).
• Breastfeeding
• Menopause.
• Chemotherapy and radiation therapy for cancer.
• Previous uterine surgery with subsequent scarring (for example, if you had a dilation and curettage, often called D&C).

Other causes of secondary amenorrhea can include:

• Stress.
• Poor nutrition.
• Weight changes — extreme weight loss or obesity.
• Exercises associated with low weight.
• Ongoing illness or chronic illness.
• You may also have conditions that can cause secondary amenorrhea.
• Primary ovarian insufficiency, when you experience menopause before age 40.
• Pituitary disorders, such as a benign pituitary tumor or excessive production of prolactin.
• Other hormonal problems, such as polycystic ovary syndrome, adrenal disorders or hypothyroidism.
• Ovarian tumors.
• Surgery to remove uterus or ovaries.

Depending upon symptoms, physical findings on examination, and thorough investigations treatment is planned.

Investigations-

• Blood tests to check hormone levels and detect thyroid or Pituitary, adrenal gland disorders.
• Genetic testing, if you have primary ovarian insufficiency and are younger than 40.
• Ultrasonography- Abdominal and Pelvic scan.
• MRI, if your provider suspects a problem with the pituitary gland or hypothalamus.

Treatment-

• If your period stopped because of menopause or pregnancy, your provider will not need to treat it. In other cases, your treatment will depend on the cause and may include:
• Losing weight through dieting and exercise (if excess weight is the cause.
• Gaining weight through an individualized diet plan (if extreme weight loss is the cause).
• Stress management techniques.
• Changing exercise levels.
• Hormonal treatment (medication), as prescribed by your Gynecologist.
• Surgery (in rare cases) in tumors like Adrenal, pituitary, or Hypothalamic.

 Amenorrhea may be a symptom of anorexia nervosa, an eating disorder. If you or a loved one has this condition, talk to a healthcare provider immediately so you can get the right treatment.

Menstrual Cramps (Dysmenorrhoea)

Having your periods can be one of the most physically and emotionally exhausting times of the month if it is associated with pain, discomfort and cramping. Pain is usually felt in the lower abdomen, lower back and in some lower limbs. It’s normal for 50 – 55% of women to have mild abdominal cramps on the first day or two of their period, about 10% of women experience severe pain.

There are two types of dysmenorrhea:

• Primary dysmenorrhea is menstrual pain that is not a symptom of an underlying gynecologic disorder but is related to the normal process of menstruation. Primary dysmenorrhea is the most common type of dysmenorrhea, affecting more than 50% of women, and quite severe in about 10%. Primary dysmenorrhea is more likely to affect girls during adolescence. Fortunately for many women, the problem eases as they mature, particularly after a pregnancy. Although it may be painful and sometimes debilitating for brief periods of time, it is not harmful.
• Secondary dysmenorrhea a Menstrual pain that is generally related to some kind of gynecologic disorder. Most of these disorders can be easily treated with medications or surgery. Secondary dysmenorrhea is more likely to affect women during adulthood.

Causes

Primary dysmenorrheal – caused by excessive levels of prostaglandins that make your uterus contract during menstruation. Lack of exercise, psychological or social stress, smoking, drinking alcohol, being overweight increases the levels of prostaglandins.

 Secondary dysmenorrhea may be caused by a number of conditions:

• Fibroids –benign tumours that develop within the uterine wall or are attached to it.
• Adenomyosis –the tissue that lines the uterus (called the endometrium) begins to grow within its muscular walls.
• A sexually transmitted infection (STI).
• Endometriosis– fragments of the endometrial lining that is found on other pelvic organs.
• Pelvic inflammatory disease (PID), which is primarily an infection of the fallopian tubes, but can also affect the ovaries, uterus, and cervix.
• The use of an intrauterine device (IUD), a birth control method.

Symptoms of dysmenorrheal –  Main symptom is usually a sharp cramp in the lower abdomen during menstruation and may also be felt in the lower back, or thighs or lower limbs. Other associated symptoms are nausea, vomiting, diarrhoea, lightheadedness, or general achiness.

For most women, the pain usually starts before or during their menstrual period, peaks within 24 hours, and subsides after 2 to 3 days. Sometimes clots or pieces of bloody tissue from the lining of the uterus are expelled from the uterus, causing pain.

Dysmenorrhea pain may be spasmodic (sharp pelvic cramps at the start of menstrual flow) or congestive (deep, dull ache). The symptoms of secondary dysmenorrhea often start sooner in the menstrual cycle than those of primary dysmenorrhea and usually last longer.

Management of Menstrual Cramps(Dysmenorrhoea): And they need some kind of treatment so that their work does not suffer.

• Rest -lying on your back, supporting your knees with a pillow.
• Avoid strenuous physical activity.
• Holding a heating p1ad or hot water bottle on your abdomen or lower back.
• Taking a warm bath.
• Gently massaging your abdomen.
• Doing mild exercises like stretching, walking, or biking – exercise may improve blood flow and reduce pelvic pain.
• Getting plenty of rest and avoiding stressful situations as your period approaches.
• Yoga, Accupressure and Accupuncture.
• Pain killers- Are effective in relieving the pain like Ibuprofen, ibuprofen and paracetamol combination, aceclofenac alone or in combination with paracetamol. To relieve the pain, painkillers should be taken as soon as the pain starts and mild in nature. If one starts when pain has become very severe then it takes time to give relief. It is recommended that one should use hot fomentation also along with painkillers once the pain becomes very severe.  They should always be taken full stomach. If taken empty stomach they can have side effects of nausea, dyspepsia, peptic ulcer

Hormonal pills- Use of Hormonal pills can improve or relieve symptoms of primary dysmenorrheal if given for few cycles in cases where no cause is found and it is not relieve by above mentioned measures. Now a day’s lot many low dose oral pills are available which your Doctor can prescribe after investigating you thoroughtly. Usually, no investigations are recommended for Dysmenorrhoea of young adolescents.

Treatments of Secondary Dysmenorrhoea- Will depend upon the cause and your doctor will guide you accordingly.

Premenstrual syndrome (PMS)

Premenstrual syndrome (PMS) has a wide variety of signs and symptoms, including mood swings, tender breasts, food cravings, fatigue, irritability, and depression. It’s estimated that as many as 3 of every 4 menstruating women have experienced some form of premenstrual syndrome.

Symptoms include- Symptoms tend to recur in a predictable pattern.

• Tension or anxiety
• Depressed mood
• Crying spells
• Mood swings and irritability or anger
• Appetite changes and food cravings
• Trouble falling asleep (insomnia)
• Social withdrawal
• Poor concentration
• Change in libido
• Headache
• Fatigue
• Weight gain related to fluid retention
• Abdominal bloating
• Breast tenderness
• Acne flare-ups
• Constipation or diarrhea

Premenstrual Dysphoric Disorder (PMDD)–

For some, the physical pain and emotional stress are severe enough to affect their daily lives. Regardless of symptom severity, the signs and symptoms generally disappear within four days after the start of the menstrual period for most women.

But a small number of women with premenstrual syndrome have disabling symptoms every month. This form of PMS is called premenstrual dysphoric disorder (PMDD).

PMDD signs and symptoms include depression, mood swings, anger, anxiety, feeling overwhelmed, difficulty concentrating, irritability, tension, and sometimes may become suicidal.

Treatment-

Lifestyle changes-

•  Exercise- Engage in at least 30 minutes of brisk walking, cycling, swimming, or other aerobic activity most days of the week. Regular daily exercise can help improve your overall health and alleviate certain symptoms, such as fatigue and a depressed mood.
• Reduce stress.
• Get plenty of sleep.
• Practice progressive muscle relaxation or deep-breathing exercises to help reduce headaches, anxiety or trouble sleeping (insomnia).
• Try yoga or massage to relax and relieve stress.
•  Avoid caffeine and alcohol.
•  Nonsteroidal anti-inflammatory drugs (NSAIDs). Taken before or at the onset of your period, NSAIDs such as ibuprofen or naproxen sodium can ease cramping and breast discomfort.
• Diuretics-  When exercise and limiting salt intake aren’t enough to reduce the weight gain, swelling, and bloating of PMS, taking water pills (diuretics) can help your body shed excess fluid through your kidneys. Spironolactone (Aldactone) is a diuretic that can help ease some of the symptoms of PMS.
• Hormonal contraceptives. These prescription medications stop ovulation, which may bring relief from PMS symptoms.
•  Antidepressants- In PMDD your doctor may prescribe antidepressants to reduce stress, anxiety, and depression.

Laparoscopic Surgery in Indore

Laparoscopy is a type of surgical procedure that allows a surgeon to access, diagnose a wide range of conditions and operate inside of the abdomen (tummy) and pelvis without having to make large incisions in the skin.This procedure is also known as keyhole surgery or minimally invasive surgery.

This type of surgery uses a small tube that has a light source and a camera, which relays images of the inside of the abdomen or pelvis to a television monitor.

The advantages of this technique over traditional open surgery include:

• A shorter hospital stay and faster recovery time
• Less pain and bleeding after the operation
• Reduced scarring

Uses of Laparoscopy-

Laparoscopy help diagnose a wide range of conditions that develop inside the abdomen or pelvis. It can also be used to carry out surgical procedures, such as removing a damaged or diseased organ, or removing a tissue sample for further testing (biopsy)

How laparoscopy is done

Laparoscopy is carried out under General Anesthesia, so you won’t feel any pain during the procedure.

During laparoscopy, the surgeon makes one or more small incisions in the abdomen. These allow the surgeon to insert the laparoscope, small surgical tools, and a tube used to pump gas into the abdomen. This makes it easier for the surgeon to look around and operate.

After the procedure, the gas is let out of your abdomen, the incisions are closed using stitches and a dressing is applied.

You can often go home on the same day of your laparoscopy, although you may need to stay in hospital overnight

Laparoscopic procedure can be diagnostic or Operative-

Diagnostic Laparoscopy –

used to see inside of abdomen and diagnose certain conditions and diseases like endometriosis, blocked Fallopian tubes, Genital Tuberculosis, Pelvic inflammatory disease etc.

Operative Laparoscopy –

used to do various surgical procedures like-

• Removal of Endometriotic cyst
• Removal of Ovarian cyst
• Hysterectomy
• Removal of fibroids
• Removal of tubes or ovaries
• Family planning operation- Tubectomy
• Bladder neck suspension for incontinence
• Infertility Surgery
• Pelvic floor repair for prolapsed

Complications of Laparoscopic Surgery–   

The risks associated with laparoscopy surgery include:

• Risk of damage to internal structures, such as blood vessels, the stomach, bowel, bladder, or ureter.
• Bleeding and the potential need for a blood transfusion.
• Infection
• Hernia
• Adverse reactions to anaesthesia