Uterine Health- 02

1- Adenomyosis: Symptoms, Causes, and Treatments
2- Enlarged Uterus
3- Prolapsed Uterus
4- D and C (Dilation and Curettage)
5- Types of Hysterectomy
6- Hysterectomy Recovery: What to Expect
7- Alternatives to Hysterectomy

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4- D and C (Dilation and Curettage)

D and C (Dilation and Curettage)

Dilation and curettage (D&C) is a brief surgical procedure in which the cervix is dilated and a special instrument is used to scrape the uterine lining. Knowing what to expect before, during, and after a D&C may help ease your worries and make the process go more smoothly. Here's what you need to know.

Reasons for a D&C

You may need a D&C for one of the several reasons. It's done to:

• Remove tissue in the uterus during or after a miscarriage or abortion or to remove small pieces of placenta after childbirth. This helps prevent infection or heavy bleeding.
• Diagnose or treat abnormal uterine bleeding. A D&C may help diagnose or treat growths such as fibroids, polyps, hormonal imbalances, or uterine cancer. A sample of uterine tissue is viewed under a microscope to check for abnormal cells.

What to Expect When Having a D&C

You can have a D&C in your doctor's office, an outpatient clinic, or the hospital. It usually takes only 10 to 15 minutes, but you may stay in the office, clinic, or hospital for up to five hours.

Before a D&C, you will have a complete history taken and sign a consent form. Ask your doctor any questions you have about the D&C. Be sure to tell the doctor if:

• You suspect you are pregnant.
• You are sensitive or allergic to any medications, iodine, or latex.
• You have a history of bleeding disorders or are taking any blood-thinning drugs.

You will receive anaesthesia, which your doctor will discuss with you. The type you have depends on the procedure you need.

• If you have general anaesthesia, you will not be awake during the procedure.
• If you have spinal or epidural (regional) anaesthesia, you will not have a feeling from the waist down.
• If you have local anaesthesia, you will be awake and the area around your cervix will be numbed.

Before the D&C, you may need to remove clothing, put on a gown, and empty your bladder.

During a D&C, you lie on your back and place your legs in stirrups like during a pelvic exam. Then the doctor inserts a speculum into the vagina and holds the cervix in place with a clamp. Although the D&C involves no stitches or cuts, the doctor cleanses the cervix with an antiseptic solution.

A D&C involves two main steps:

• Dilation involves widening the opening of the lower part of the uterus (the cervix) to allow insertion of an instrument. The doctor may insert a slender rod (laminaria) into the opening beforehand or use a medication before the procedure to soften the cervix and cause it to widen.
• Curettage involves scraping the lining and removing uterine contents with a long, spoon-shaped instrument (a curette). The doctor may also use a cannula to suction any remaining contents from the uterus. This can cause some cramping. A tissue sample then goes to a lab for examination.

Sometimes other procedures are performed along with a D&C. For example, your doctor may insert a slender device to view the inside of the uterus (called hysteroscopy).

After a D&C, there are possible side effects and risks. Common side effects include:

• Cramping
• Spotting or light bleeding

Complications such as a damaged cervix and perforated uterus or bladder and blood vessels are rare. But be sure to contact your doctor if you have any of the following symptoms after a D&C:

• Heavy or prolonged bleeding or blood clots
• Fever
• Pain
• Abdominal tenderness
• Foul-smelling discharge from the vagina

In very rare cases, scar tissue (adhesions) may form inside the uterus. Called Asherman's syndrome, this may cause infertility and changes in menstrual flow. Surgery can repair this problem, so be sure to report any abnormal menstrual changes after a D&C.

Recovery After a D&C

After a D&C, you will need someone to take you home. If you had general anaesthesia, you may feel groggy for a while and have some brief nausea and vomiting. You can return to regular activities within one or two days. In the meantime, ask your doctor about any needed restrictions. You may also have mild cramping and light spotting for a few days. This is normal. You may want to wear a sanitary pad for spotting and take pain relievers for pain.

You can expect a change in the timing of your next menstrual period. It may come either early or late. To prevent bacteria from entering your uterus, delay sex and use of tampons until your doctor says it's OK.

See your doctor for a follow-up visit and schedule any further treatment that's needed. If any tissue was sent for a biopsy, ask your doctor when to expect results. They are usually available within several days.

5- Types of Hysterectomy

Hysterectomy

A hysterectomy is an operation to remove a woman's uterus. A woman may have a hysterectomy for different reasons, including:

• Uterine fibroids that cause pain, bleeding, or other problems
• Uterine prolapse, which is a sliding of the uterus from its normal position into the vaginal canal
• Cancer of the uterus, cervix, or ovaries
• Endometriosis
• Abnormal vaginal bleeding
• Chronic pelvic pain
• Adenomyosis, or a thickening of the uterus

Hysterectomy for noncancerous reasons is usually considered only after all other treatment approaches have been tried without success.

Types of Hysterectomy

Depending on the reason for the hysterectomy, a surgeon may choose to remove all or only part of the uterus. Patients and health care providers sometimes use these terms inexactly, so it is important to clarify if the cervix and/or ovaries are removed:

• In a supracervial or subtotal hysterectomy, a surgeon removes only the upper part of the uterus, keeping the cervix in place.
• A total hysterectomy removes the whole uterus and cervix.
• In a radical hysterectomy, a surgeon removes the whole uterus, tissue on the sides of the uterus, the cervix, and the top part of the vagina. Radical hysterectomy is generally only done when cancer is present.

The ovaries may also be removed -- a procedure called oophorectomy -- or may be left in place. When the tubes are removed that procedure is called salpingectomy. So, when the entire uterus, both tubes, and both ovaries are removed, the entire procedure is called a hysterectomy and bilateral salpingectomy-oophorectomy.

Surgical Techniques for Hysterectomy

Surgeons use different approaches for hysterectomy, depending on the surgeon’s experience, the reason for the hysterectomy, and a woman's overall health. The hysterectomy technique will partly determine healing time and the kind of scar, if any, that remains after the operation.

There are two approaches to surgery - a traditional or open surgery and surgery using a minimally invasive procedure or MIP.

Open Surgery Hysterectomy

An abdominal hysterectomy is an open surgery. This is the most common approach to hysterectomy, accounting for about 65% of all procedures.

To perform an abdominal hysterectomy, a surgeon makes a 5- to 7-inch incision, either up-and-down or side-to-side, across the belly. The surgeon then removes the uterus through this incision.

Following an abdominal hysterectomy, a woman will usually spend 2-3 days in the hospital. There is also, after healing, a visible scar at the location of the incision.

MIP Hysterectomy

There are several approaches that can be used for an MIP hysterectomy:

• Vaginal hysterectomy: The surgeon makes a cut in the vagina and removes the uterus through this incision. The incision is closed, leaving no visible scar.
• Laparoscopic hysterectomy: This surgery is done using a laparoscope, which is a tube with a lighted camera, and surgical tools inserted through several small cuts made in the belly or, in the case of a single site laparoscopic procedure, one small cut made in the belly button. The surgeon performs the hysterectomy from outside the body, viewing the operation on a video screen.
• Laparoscopic-assisted vaginal hysterectomy: Using laparoscopic surgical tools, a surgeon removes the uterus through an incision in the vagina.
• Robot-assisted laparoscopic hysterectomy: This procedure is similar to a laparoscopic hysterectomy, but the surgeon controls a sophisticated robotic system of surgical tools from outside the body. Advanced technology allows the surgeon to use natural wrist movements and view the hysterectomy on a three-dimensional screen.

Comparison of MIP Hysterectomy and Abdominal Hysterectomy

Using an MIP approach to remove the uterus offers a number of benefits when compared to the more traditional open surgery used for an abdominal hysterectomy. In general, an MIP allows for faster recovery, shorter hospital stays, less pain and scarring, and a lower chance of infection than does an abdominal hysterectomy.

With an MIP, women are generally able to resume their normal activity within an average of three to four weeks, compared to four to six weeks for an abdominal hysterectomy. And the costs associated with an MIP are considerably lower than the costs associated with open surgery, depending on the instruments used and the time spent in the operating room. Robotic procedures, however, can be much more expensive. There is also less risk of incisional hernias with an MIP.

Not every woman is a good candidate for a minimally invasive procedure. The presence of scar tissue from previous surgeries, obesity, and health status can all affect whether or not an MIP is advisable. You should talk with your doctor about whether you might be a candidate for an MIP.

Risks of Hysterectomy

Most women who undergo hysterectomy have no serious problems or complications from the surgery. However, hysterectomy is considered a major surgery and is not without risks. Those complications include:

• Urinary incontinence
• Vaginal prolapse (part of the vagina coming out of the body)
• Fistula formation (an abnormal connection that forms between the vagina and bladder)
• Chronic pain

Other risks from hysterectomy include wound infections, blood clots, hemorrhage, and injury to surrounding organs, although these are uncommon.

What to Expect After Hysterectomy

After a hysterectomy, if the ovaries were also removed, a woman will enter menopause. If the ovaries were not removed, a woman may enter menopause at an earlier age than she would have otherwise.

Most women are told to abstain from sex and avoid lifting heavy objects for six weeks after hysterectomy.

After a hysterectomy, the vast majority of women surveyed feel the operation was successful at improving or curing their main problem (for example, pain or heavy periods).

6- Hysterectomy Recovery: What to Expect

Hysterectomy Recovery: What Can You Expect?

After a hysterectomy, you will have a brief recovery time in the hospital. Your recovery time at home -- before you can get back to all your regular activities -- will vary depending on the procedure you had.

Abdominal hysterectomy. Most women go home 2-3 days after this surgery, but complete recovery takes from six to eight weeks. During this time, you need to rest at home. You should not be doing housework until you talk with your doctor about restrictions. There should be no lifting for the first two weeks. Walking is encouraged, but not heavy lifting. After 6 weeks, you can get back to your regular activities, including having sex.

Vaginal or laparoscopic-assisted vaginal hysterectomy (LAVH). A vaginal hysterectomy is less surgically invasive than an abdominal procedure, and recovery can be as short as two weeks. Most women come home the same day or the next. Walking is encouraged, but not heavy lifting. You will need to abstain from sex for at least 6 weeks.

Laparoscopic supracervical hysterectomy (LSH). This procedure is the least invasive and can have a recovery period as short as six days to two weeks. Walking is encouraged, but not heavy lifting.

Robotic hysterectomy. The surgeon's movements are mimicked by robotic arms that make small incisions to remove the uterus. Most women come home the next day. If the cervix is removed, you will have the same restrictions as you would have for a LAVH.

Call your doctor if you have any of these symptoms with any type of hysterectomy:

• Fever or chills
• Heavy bleeding or unusual vaginal discharge
• Severe pain
• Redness or discharge from incisions
• Problems urinating or having a bowel movement
• Shortness of breath or chest pain

Your Hysterectomy Recovery

For most women, life without a uterus means relief from the symptoms that caused them to have a hysterectomy -- bleeding, pelvic pain, and abdominal bloating. With relief from those symptoms, women may have better sex -- with greater libido, frequency, and enjoyment.

Yet if the ovaries were removed, there are a few more challenges ahead. If you had not gone through menopause before your hysterectomy, you probably will begin having symptoms of menopause -- hot flashes and mood swings. Your body is adjusting to changes in hormone levels. You may also have some changes in sexual desire and enjoyment and vaginal dryness. Most women begin hormone replacement therapy before they leave the hospital because bodily changes can be so drastic.

You may feel a sense of loss. You may grieve over the loss of your uterus and your ability to have children. If you had surgery because of illness or cancer, you may feel depressed. These feelings are normal. Talk to your doctor and a mental health therapist about them. Most women, however, are happy after their hysterectomy.

Treating Side Effects of Hysterectomy

You may want to consider hormone replacement therapy (HRT) to ease some symptoms. Your age, medical history, and whether you have had ovaries removed are factors to consider when deciding on HRT. Talk the issues over with your doctor. If you have had breast cancer, HRT is not appropriate for you.

There are non-hormonal treatments that can help. Effexor and other SSRI antidepressants, Clonidine (a blood pressure medication), and Neurontin(prescribed for seizures and chronic pain) have been found to be effective in treating hot flashes.

Some women experience pain during intercourse after a hysterectomy. It helps to try different positions and lubricants and moisturizers (like K-Y oils or Replens). A low-dose vaginal estrogen cream, suppository or ring can also help relieve vaginal dryness.

Pelvic weakness sometimes develops after a hysterectomy. If you had some pelvic weakness before surgery, it may get worse afterwards -- leading to bladder or bowel problems. Kegel exercises can help strengthen pelvic muscles to help control urinary incontinence problems. For some women, corrective surgery is necessary.

7- Alternatives to Hysterectomy

Alternatives to Hysterectomy

One-third of American women experience some type of pelvic health disorder by the time they're age 60. And about 600,000 women every year have a hysterectomy -- removing their uterus to relieve troubling symptoms. Overall, an estimated 20 million women have had a hysterectomy.

But if you have painful periods with excessive bleeding, fibroids, endometriosis, or another pelvic health problem, you should know that there are alternatives to hysterectomy to consider.

Uterine Fibroids

These tumors, usually benign, are generally found on the smooth muscles of the uterus, and can cause pelvic pain, infertility, and heavy menstrual bleeding. Uterine fibroids are a major reason why women have hysterectomies, accounting for between 177,000 and 366,000 of the annual total.

If your fibroids are causing no symptoms, it's entirely reasonable to adopt a strategy called "watchful waiting" -- monitoring their status with your doctor and not having any surgery unless problems develop. But if you are experiencing pain, discomfort, or pressure, there are several less-invasive options for treating fibroids:

• Myomectomy. This is the surgical removal of the fibroids alone. It can be done through an abdominal operation, laparoscopically (entering through the navel), or via hysteroscopy (inserting a thin, telescope-like instrument called a hysteroscope through the vagina). A laparoscopic or hysteroscopic approach is least invasive, and these are also less costly and require shorter recovery time. The da Vinci robotic myomectomy is another technique that offers precision and smaller incisions. There is a small chance that what was thought to be a fibroid could instead be a cancer called uterine sarcoma. For this reason, the FDA recommends not cutting the fibroid into small sections before removing it, a process called laparoscopic morcellation.
• Uterine artery embolization (UAE), also known as uterine fibroid embolization (UFE). This is a fairly simple, noninvasive procedure in which small particles are injected into the uterine arteries feeding the fibroids, cutting off their blood supply. Unlike a hysterectomy, this procedure preserves the uterus and helps women potentially avoid surgery. It's been used for years to help stop hemorrhage after childbirth or surgery. Symptoms improve in 85% to 90% of patients, most of them significantly.
• Hysteroscopy. The insertion of a thin, telescope-like instrument through the vagina can be used if the fibroid is primarily within the cavity of the uterus. This is a minor surgical procedure with minimal recuperation time, but can only be offered to women who have fibroids within the lining of the uterine cavity.
• Medical management. Painful symptoms of uterine fibroids can be initially treated with nonsteroidal anti-inflammatory drugs (NSAIDs), like Motrin. If that isn't effective, another option is a class of drugs that blocks the ovaries' production of estrogen and other hormones. Their side effects can include symptoms of premature menopause and a decrease in bone density. This is done only prior to scheduled fibroid removal, not long term. The fibroids will grow again after therapy is stopped.

Menorrhagia

Menorrhagia means heavy vaginal bleeding. In many cases, the bleeding has a known cause, like uterine fibroids (see above), but in other cases the cause remains unknown. There's a medical threshold for menorrhagia -- losing more than 80 mL of blood in each menstrual cycle -- but most doctors now tend to define menorrhagia by how much it affects your daily life: causing pain, mood swings, and disruptions in your work, sexual activity, and other activities.

Some options for treating menorrhagia, short of hysterectomy:

• Medical management. Menorrhagia's first treatment of choice is medical, using either oral contraceptives or an intrauterine device(IUD) that releases a hormone called levonorgestrel. Both of these treatments reduce menstrual bleeding significantly, although women report being generally more satisfied with the IUD. If you're still planning to have children in the future, these are probably your best options.
• Endometrial ablation. There are a variety of techniques that can be used to remove the lining of the uterus. You should only consider these options, however, if you are done with childbearing. New, "second-generation" methods like thermal balloon ablation, cryoablation, and radiofrequency ablation have success rates up to 80%-90%. These are all outpatient procedures mostly done in the doctor's office, so they don't have the same complication rates and extended hospital stays involved in hysterectomy.
• Occasionally, an NSAID is prescribed during menses to help reduce blood flow to the uterine lining.

Uterine Prolapse

Uterine prolapse happens when your uterus drops from its normal position and pushes against your vaginal walls. It can be caused by a number of things, but one of the most common causes is vaginal childbirth. Advancing age, smoking, pregnancy, and obesity are also significant risk factors.

Obviously, a hysterectomy will solve this problem -- but there are less drastic approaches that you can also consider. One treatment option is a vaginal pessary -- a removable device placed into the vagina to support areas where prolapse is happening. There are several different kinds of pessaries, and your doctor can help you decide which is best for your situation. They don't cure the prolapse, but can relieve symptoms partially or completely. Often, they can be helpful in pregnancy, holding the uterus in place before it enlarges and invades the vaginal canal.

There are also multiple surgical methods for treating uterine prolapse, and surgeons may use more than one technique. Sometimes, they will have to be combined with a hysterectomy, but for some women it is possible to avoid this step.

The risks of placing mesh through the vagina to repair pelvic organ prolapse -- a procedure done roughly 75,000 times in 2010 -- may outweigh its benefits, according to the FDA. However, the use of mesh may be appropriate in some situations.

Other types of surgery include paravaginal defect repairs and repairs of enteroceles, rectoceles (hernias of the intestine or rectum into the vagina), and cystoceles prolapse of the bladder into the vagina.

Endometriosis

About 5 million American women experience endometriosis, which occurs when tissue that behaves like the lining of the uterus -- the endometrium -- grows in other areas of the abdominal cavity, such as the ovaries, fallopian tubes, or outer surface of the uterus. Symptoms include pelvic pain, painful intercourse, spotting between periods, and infertility. The average woman with endometriosis has symptoms for two to five years before being diagnosed.

About 18% of hysterectomies in the U.S. are performed due to endometriosis -- and it doesn't necessarily cure the problem. As many as 13% of women see their endometriosis return within three years if their ovaries are intact; the number climbs to 40% in five years. And since endometriosis often affects young women -- with an average age of about 27 -- a surgical option that removes all possibility of pregnancy isn't really an alternative.

Treatments for endometriosis depend on the severity of the symptoms and the woman's needs. For example, pain can be treated with over-the-counter or prescription pain relievers. To treat pain and abnormal menstrual bleeding, women may be prescribed hormonal treatments such as birth control pills or drugs that drastically reduce estrogen levels. These drugs, however, aren't for women who are trying to get pregnant, and they are not a permanent treatment: Going off the medication usually means the endometriosis symptoms come back.

A more long-term treatment for endometriosis that is more likely to help with fertility problems is laparoscopic surgery, a minimally invasive approach to either remove the endometrial growths and scar tissue, or burn them away with intense heat. If the growths can't all be safely destroyed this way, surgeons can take a more invasive approach, a laparotomy, which involves making a larger cut in the abdomen. This requires a much longer recovery period, but is still less invasive than hysterectomy and offers the prospect of retaining fertility.

Chronic Pelvic Pain

Chronic pelvic pain affects many women: Some studies indicate that as many as 39% of women have some kind of chronic pelvic pain. It's most common in younger women, especially those between 26 and 30 years old.

Pelvic pain can be caused by many things, including the above-mentioned uterine fibroids and endometriosis, pelvic inflammatory disease, and bowel and bladder issues like irritable bowel syndrome, interstitial cystitis(an inflamed bladder), and musculoskeletal issues. Women who have experienced sexual abuse are also more likely to experience chronic pelvic pain.

A hysterectomy should be considered a last resort for chronic pelvic pain, especially since many types of pelvic pain aren't cured by the surgery. It's important to work with your doctor to uncover the specific cause of your pain so that the treatment can be targeted to that cause, giving you the best chance of relief. For example, if you are diagnosed with uterine fibroids or endometriosis, one of the treatment options described above might have the best chance of putting an end to chronic pelvic pain.

Other treatment options, depending on the cause of your pain, may include:

• Stopping ovulation with hormonal methods like birth control pills
• The use of nonsteroidal anti-inflammatory medications
• Relaxation exercises, biofeedback, and physical therapy
• Abdominal trigger point injections; medication injected into painful areas in the lower wall of the abdomen can help relieve pain.
• Antibiotics (if an infection, such as pelvic inflammatory disease, is the source of the pain)
• Psychological counseling

It's still possible that, whatever your health condition might be, a hysterectomy may be the most effective and appropriate treatment. But with many alternatives available, it's important to discuss all your options with your doctor first.