Female Disorders

The female reproductive system is made up of two ovaries, two fallopian tubes, a uterus (womb), cervix, vagina, and the vulva (external genitalia). Each ovary connects to a fallopian tube, which connects to the uterus; this rests above the cervix and the vagina. The ovaries consist of fluid filled sacs called follicles, which contain the eggs in an immature state. Hormones are needed for the eggs to grow and mature each month from puberty to the menopause. The fallopian tubes carry the eggs towards the uterus and if sperm are present, the egg is usually fertilized here. The developing embryo will travel down the fallopian tube to the uterus and it is in the uterus that the embryo will implant (attaching to the lining of the womb where it has a blood supply from the mother). The vagina is a tube, which connects the uterus to the external genitalia and is where the penis is inserted during sexual intercourse. Sperm are released in the vagina and need to swim through the cervix and uterus and down the fallopian tube to meet the egg for fertilization. Externally the female genitalia are referred to as the vulva, which is made up of the clitoris, urethra (which leads to the bladder and allows for the passage of urine), and the labia majora and labia minora (these are the fleshy lips of the vulva). The vagina allows for the passage of the menstrual blood and also the baby during pregnancy and delivery.

There are many disorders that can affect the female reproductive system and can be caused by infections, physical damage or hormone imbalances. Some disorders can lead to infertility.

Polycystic Ovarian Syndrome (PCOS)

PCOS is a common condition that can affect a woman’s menstrual cycle, fertility and appearance. The cause is unknown but the balance of hormones produced by the ovaries is affected, and in some women, the testosterone level is slightly higher than normal. Women with PCOS tend to have larger ovaries, filled with multiple, fluid filled follicles (cysts), but although one in every five women will have polycystic ovaries, only one in twenty of these will have the syndrome. It affects women of childbearing age and can run in families. PCOS also affects long-term health.

Symptoms Of PCOS

Irregular periods, or no periods at all
Difficulty becoming pregnant
Excess hair on the face or body (hirsutism)
Weight gain and difficulty losing weight
Thinning of hair on your head
Oily skin and acne
Mood swings and irritability

What Causes PCOS?

The cause of PCOS is not fully understood but we know that it can run in families, and you are more likely to be affected if a close relative has it. The imbalance of hormones produced by the ovary results in some of the symptoms of PCOS, but insulin levels (a hormone which controls blood sugar levels) may also be raised, which in turn leads to weight gain, irregular periods, difficulty getting pregnant and will increase testosterone levels further.

How Is PCOS Diagnosed?

The symptoms and appearance of multiple cysts on the ovaries can come and go, so it can take a while to be diagnosed. Two of the following must be present for make a diagnosis of PCOS:

Irregular (some cycles >6 weeks apart) or no periods
Excess facial or body hair, or higher than normal testosterone levels on a blood test
Ultrasound scan showing polycystic ovaries

Treatments For PCOS

There is no cure for PCOS, but various treatments can help improve symptoms. The treatment tried by your doctor will depend on the symptoms you have, and whether or not you are trying to become pregnant.

The first step is to make sure you have a healthy lifestyle, eat plenty of fruit and vegetables and take at least 30 minutes of sweat-inducing exercise per day. This helps to reduce the insulin hormone levels, helps weight loss and will also make you feel better about yourself. It is important to keep your weight within a healthy range, because your PCOS symptoms will be less severe. If you are trying to become pregnant, losing weight is often enough to achieve this, without having to undergo fertility treatments. Whilst weight loss may be more difficult with PCOS, it is by no means impossible.

Irregular periods can be helped by starting the hormone contraceptive pill to regulate your cycle. If the few periods you do get are extremely heavy and/or painful, the pill will help improve this too.

Using topical creams can treat excess hair growth on the body and face, and some hormonal contraceptive pills can also help. The treatments tend to work slowly over several weeks. Other strategies include waxing and shaving. Laser hair removal is helpful but not available on the NHS.

Some doctors may prescribe you a treatment usually used for people with diabetes. This drug is called metformin, and helps reduce insulin levels. It is most commonly used to help women ovulate more regularly in order to become pregnant. However, there is not good evidence that it works reliably and other options may be better for you.

If you are having difficulty becoming pregnant, your doctor may refer you to the hospital to see a fertility specialist. A fertility specialist will want to investigate both you and your partner’s fertility in order to offer the right treatment for you. Most of the time, the difficulty in getting pregnant comes from not ovulating (releasing eggs from the ovary) on a regular basis. However, it is important to check that your tubes and womb look healthy, and that your partner’s sperm is healthy, before offering you drugs to help you to release eggs. This drug is called clomiphene citrate, and can only be prescribed for a limited period of time, if your body mass index (a measure of weight) is in the normal or just above normal range.

Long-term Health Problems With PCOS

The risk of developing insulin resistance and diabetes is increased, and one in ten women will go on to develop diabetes. This risk is increased further in women over 40 years old, have relatives with diabetes, had diabetes in pregnancy (gestational diabetes) or have a body mass index (BMI) over 30.

Women with PCOS have an increased chance of developing high blood pressure. The risk is higher if you are overweight, and is a reason that keeping your weight within the healthy range is important.

PCOS increases the chance of developing cancer of the womb lining (endometrial cancer), because in having very few periods, the womb lining becomes thickened, and can over-grow. Taking the pill, or hormone tablets to induce a period every 3-4 months reduces this risk. The risk of breast, ovarian or cervical cancer is not increased from PCOS, but being overweight does increase the risk.

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Endometriosis

This is a common disorder where the tissues that line the womb (endometrium) are found outside the womb, on surfaces of other organs within the body. Most commonly, the tissue is found on the tubes, ovaries and on the lining of the pelvis, but it can be found anywhere within the tummy, such as the bowel and bladder. If you have endometriosis, when you have a period these deposits of tissue bleed into the tummy and cause pain. If the endometriosis has been there for a long time, it can lead to the formation of scar tissue. This scar tissue can cause long-term pain.

Symptoms

Painful and/or heavy periods
Abdominal and pelvic pain which is often related to your menstrual cycle
Deep pelvic pain during sexual intercourse
Difficulty becoming pregnant
Lack of energy
Depression

What Causes Endometriosis?

The cause is unknown, but may be due to cells from the womb lining forming in the wrong place during development as a fetus in your mother’s womb. Another theory is that cells from the womb lining travel backwards down the fallopian tubes during a period, and implant on surfaces within the tummy.

How Is It Diagnosed?

A diagnosis of endometriosis can be difficult to make because the symptoms can very so much, and be very similar to symptoms of other conditions. The best way to diagnose endometriosis is by laparoscopy (key hole surgery) in which a small camera is inserted through the tummy button, giving a magnified view of the inside of the tummy and pelvis. This requires a general anesthetic. If endometriosis is seen at this time, the doctor can destroy or remove the endometriosis and release any scar tissue. Sometimes, the endometriosis is so extensive that you may need to be referred to a specialist endometriosis treatment centre for further surgery.

Treatment

Endometriosis is treated using hormones such as the contraceptive pill, the Mirena (hormone) coil, and/or surgery. Surgery can improve your chance of getting pregnant. For women with long-term pain, referral to a pain clinic can be very helpful. Removing the womb and ovaries is a last resort.

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Pelvic Inflammatory Disease (PID)

Bacteria can travel up the vagina, through a tiny opening in the cervix (neck of the womb) and into the womb, fallopian tubes, ovaries and pelvis. PID is an infection of the womb, fallopian tubes, ovaries and pelvis. These bacteria can be from a sexually transmitted disease such as chlamydia or gonorrhea, or they may be normal bacteria from the vagina. PID can have no symptoms, mild symptoms or severe symptoms. Sometimes symptoms are similar to those seen with appendicitis. PID can also occur after contraceptive coil insertion and some gynaecological surgery (such as surgical management of miscarriage, termination of pregnancy or hysteroscopy – a camera test to check the womb lining).

Mild PID Symptoms

Pelvic pain
Pain during intercourse
Pain during urination
Unusual discharge
Heavy or painful periods

Severe PID Symptoms

Severe abdominal pain
Nausea and vomiting
Fever

Causes

PID can have many causes but 1 in 4 cases are caused by a sexually transmitted disease (STD) including gonorrhea and chlamydia. PID can cause infertility by scarring the fallopian tubes, causing them to block and this is especially problematic when the woman has had no symptoms and she only realizes when she tries to get pregnant.

How Is It Diagnosed?

There is no simple test for PID but anyone with the above symptoms should visit their doctor or clinic immediately. Swabs will be taken from the vagina and cervix to check for bacteria. It is important to use barrier contraception and get tested regularly for sexually transmitted diseases in order to prevent PID from occurring. If PID is suspected from your symptoms, it is better to treat it early with antibiotics rather than wait for swab results, because of the potential effect on your fertility.

Treatment Of PID

Most of the time, PID can be treated with a course of antibiotics taken by mouth for 14 days, with or without a one-off injection at the beginning of the course. During treatment you should not have sexual intercourse, and your partner should be tested for STDs before you resume having sex.

If your symptoms are severe, you may need to be admitted to hospital for intravenous antibiotics (a drip). During your stay in hospital, you may have an ultrasound scan of your pelvis to check for evidence of tubal swelling or pockets of infection (abscess). You are unlikely to need surgery unless your infection is not improving with antibiotics.

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Pelvic Organ Prolapse

The female pelvic organs are held in place by ligaments, muscles and skin. These structures can weaken and result in a prolapse (‘falls out of place’) of the uterus, urethra, small bowel, rectum (large bowel), bladder and vagina.

The most common types of prolapse seen in women involve the womb (uterine prolapse), or bladder (cystocoele) or bowel (rectocoele). These are all caused by weakness in the pelvic floor muscles and ligaments holding the womb and top of the vagina in place. The prolapsing organ bulges into the vagina, causing a variety of symptoms. After a hysterectomy (operation to remove the womb), the top of the vagina can bulge downwards. This is called a vaginal vault prolapse.

Prolapse can happen at any age but is more common after the menopause, due to loss of oestrogen. A prolonged labour, vaginal delivery of a very large baby, smoking and being overweight all increase the risk.

Symptoms

A feeling of ‘pulling down’ or dragging in the pelvis
A bulge in the vagina
Difficulty completely emptying the bladder (bladder prolapse), sometimes requiring either standing or placing fingers into the vagina to press on the front wall to help
Difficulty completely emptying the bowel (bowel prolapse), sometimes requiring placing of fingers into the vagina to press on the back wall to help
Difficulties during intercourse including discomfort and pain

How Is Pelvic Organ Prolapse Diagnosed?

A prolapse is suspected from the symptoms, and confirmed by a doctor performing a vaginal examination. This is the type of examination from a smear test, but you may also be asked to lie on your left side in order to view the prolapse. The prolapse will be graded based on how big the bulge is, usually as grade 1, 2 or 3 (mild, moderate or severe). A prolapse cannot be diagnosed using an ultrasound scan.

How Is It treated?

A mild prolapse can be treated with exercises to strengthen the pelvic floor muscles. As well as helping to improve the prolapse, pelvic floor exercises also help treat urinary incontinence. Pelvic floor exercises should be continued for life.

Larger prolapses, or prolapses causing symptoms and affecting quality of life, can be treated using either vaginal pessaries (rubber or silicone ring shapes to hold the prolapse in place) or surgery. If you have a lot of other medical problems, a pessary may be the best and safest option.

Surgery is usually offered if the pessary has failed, it is too uncomfortable or it is affecting a woman’s sex life. The type of surgery depends on the type of prolapse involved, but may include a vaginal repair, a vaginal hysterectomy, or sometimes keyhole surgery to hitch up the prolapse internally. In women who have had surgery for a prolapse, one to two in ten will have a recurrence.

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Fibroids

Fibroids are non-cancerous (benign) growths made of womb muscle, that grow in or around the womb and about three in ten women have them. Fibroids can exist as a single lump, or there may be many of them. They vary in size from a few millimeters to many centimeters, and tend to grow slowly over time. The exact cause is unknown but their growth is linked to female hormones and they do run in families. They grow during a woman’s fertile period and reduce in size after the menopause. Women who have had children have a lower chance of having a fibroid. A woman will often not know she has fibroids until she is trying to get pregnant or during a routine gynaecology test or ultrasound scan. Some fibroids can be very large and can be easily felt with a pelvic examination and can even bulge out of the lower abdomen.

Symptoms

Feeling off fullness in the tummy
Enlargement of the tummy
Heavy periods
Abdominal pain
Lower back pain
Frequently needing to pass urine
Constipation
Discomfort during intercourse
Difficulty becoming pregnant
Problems during pregnancy, including increased risk of going into labour early, the baby being in an awkward position and growth problems

Treatment

Treatment depends on whether you have symptoms, where the fibroids are within the womb, whether you are trying to get pregnant, and how big the fibroids are.

If you have no symptoms, you do not need treatment or any further scans.

The contraceptive pill or Mirena (hormone) coil may be enough to help treat heavy periods.

If your periods are heavy, you may be offered a procedure called a hysteroscopy (camera test to check the womb lining). If a small fibroid is poking out into the womb cavity, this can be carefully shaved off and removed. Usually, this procedure requires a general anaesthetic. At the same time, a Mirena (hormone) coil can be inserted to help reduce your periods further. This procedure may also be offered if you are trying to become pregnant, although it may not help your chances of conceiving.

If you have pressure symptoms from fibroids, or your fibroids are very large and causing heavy periods, it is possible to remove them through either keyhole surgery (laparoscopic myomectomy) or through a larger cut in your tummy (open myomectomy). This operation involves making a cut in the womb wall, and shelling out the fibroids. It carries a significant risk of heavy bleeding requiring blood transfusion, and about one in ten women end up needing a hysterectomy (removal of the womb) in order to gain control of the heavy bleeding.

Before having a procedure to treat fibroids, your doctor may advise you to take a medication to block female hormones, preventing further fibroid growth or shrinking the fibroids to make removal easier. Both tablets and injections Esmya, goserelin) are available for this, but side effects are similar to the menopause and you may need to take hormone replacement therapy while you are taking these drugs.

If you have completed your family and have symptoms from your fibroids, other treatment options include uterine artery embolization and hysterectomy. Uterine artery embolization involves having a detailed scan (MRI) of your fibroids, and a small tube inserted into the top of your leg, in order that a fine catheter can be passed into the blood vessels supplying the womb to block the supply to the fibroids. This cuts off the blood supply and will shrink the fibroids over the coming weeks. It avoids having a major surgical procedure, but can cause pain and the dying fibroids can become infected. A hysterectomy involves removing the womb, either by keyhole (if the fibroids are small enough) or through the tummy. This is usually done using a general anaesthetic and involves staying in hospital for one or two nights.

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Ovarian Cysts

An ovarian cyst is a fluid filled sac that grows on or within the ovary. In the majority of cases these cysts are non-cancerous (benign) and will not cause problems. They are most commonly seen in women of childbearing age and form a follicle, containing the egg, as part of the normal menstrual cycle. Most ovarian cysts are ‘simple,’ containing only clear fluid, and resolve on their own without treatment over a few months. More ‘complex’ cysts can contain blood, sebum or solid areas and these are less likely to go away by themselves. The risk of a cyst being cancerous is low, but does increase after the menopause. If a cyst is found on a routine ultrasound scan, you may be referred to see a women’s health doctor to discuss whether or not you need any further scans, blood tests to help determine the type of cyst, or treatment.

Symptoms

There are often no symptoms at all
Pelvic pain, including painful periods if the cyst is due to endometriosis
Pain during intercourse
Swollen or bloated tummy
Frequent need to pass urine

Treatment

If the cyst is described as simple, containing only clear fluid, it will most likely resolve on its own without treatment.

Larger cysts, or those described as complex, contain solid areas, blood and/or sebum, and require monitoring with further ultrasound scans. You may be asked to have a blood test for markers which can help determine whether the type of cyst is concerning and may be cancerous. The most common test is called Ca125, and is most often performed on women after the menopause with an ovarian cyst.

Cysts are at risk of causing the ovary to twist around on its stalk, or rupture, causing sudden-onset severe abdominal pain with or without vomiting, and if this happens, you should be seen by a doctor on the same day – either your GP or in the emergency department. If the ovary is twisted on its stalk, its blood supply can be cut off, causing the ovary to die. This situation requires urgent surgery.

If you have ongoing less severe pelvic pain, or the doctor has recommended removal of the cyst, this is most commonly performed by keyhole surgery, unless the cyst is too large. In women under the age of 45, usually the cyst is peeled from the ovary (cystectomy), whereas after the menopause, if a cyst has to be removed, it is simpler to remove the entire ovary; sometimes it will be recommended that after the menopause, both ovaries are removed at the same time to prevent further cysts from forming. When an ovarian cyst is removed, it is always sent to be checked under a microscope to make sure that no cancer cells, or other conditions such as endometriosis, are present.

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Urinary Incontinence In women

Urinary incontinence is the accidental leakage of urine. It affects up to one in three women at some point in their lives, although it is more common after the menopause due to lack of oestrogen, which can thin the tissues supporting bladder control. Obesity increases the risk due to increased pressure on the bladder. Urinary tract infections can cause temporary urinary incontinence. There are two types of incontinence:

Stress incontinence occurs during coughing, laughing, exercise and sneezing. The urethra, which leads from your bladder to the outside, is unable to stay closed in response to increased pressure inside the tummy, resulting in leakage of urine. This is the most common type of incontinence in women, and is improved by weight loss and exercising the pelvic floor muscles. If this does not help, specialist help from a pelvic floor physiotherapist can improve symptoms. Some women go on to require surgery to help strengthen the pelvic floor muscles surrounding the bladder; the most common procedure for stress incontinence in women is the transvaginal tape (TVT).

Urge incontinence when you have a sudden urge and often cannot reach the toilet in time. It is caused by an overactive bladder wall muscle; this muscle is called detrusor. This condition is also known as detrusor overactivity, or overactive bladder. It is also more common after the menopause, and the cause is unknown. Frequent urinary tract infections can irritate the bladder and make the symptoms worse.

Treatment includes life style changes such as exercises and diet, bladder training and medication to calm the bladder muscle. If all of these measures fail to help, surgical procedures may be offered.

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Dr Elena Kontogianni