GESTATIONAL DIABETES: SCREENING DIAGNOSIS AND MANAGEMENT

 

Diabetes mellitus an ever increasing disease in the world. It is a chronic disease causing high blood sugars. These cause changes in the big and small blood vessels finally leading to multi organ disease e.g. brain, eyes, heart and kidneys. Type 1 diabetes occurs in children who never produce insulin. Type two occurs in adults and at present it is occurring in epidemic numbers, 1 in 11 people. This increase is in adults. So much Diabetes in the world is due to our life style factors, affluence, and lack of activity even if we have to go to the local post office we take the car. Exercise physical activity transport and too much socialization. Type 3 diabetes is gestational diabetes occurring in women for the first time during pregnancy. This happens in about 7% of women. It becomes type 2 diabetes in large numbers of females depending on their life style, subsequent pregnancies, and weight gain. Pregnancy is classified as dibetogenic. With the increasing numbers of obesity in the world, diabetic pregnancy is increasing in parallel. This is referred as Gestational Diabetes Mellitus (GDM). This has its own problems, increased blood pressure causing a complication called preeclampsia of pregnancy, big babies (Macrosomia) causing need for caesarian section or difficult deliveries, shoulder dystocia (difficulty with delivery of shoulder), intrauterine fetal deaths and so on. With these happening, the World Health Organization (WHO) decided to screen all pregnant women for diabetes during pregnancy.  Those at higher risk are screened on the first visit, others at 24 -28 weeks because the need for insulin during pregnancy increases at this time. (It is also referred as Insulin resistance meaning body’s inability to use Insulin correctly.)  Blood glucose increases in blood, not being absorbed by the body cells, muscles, fat, and liver. The main cause for this is obesity and lack of activity

Why does the need for insulin increases during pregnancy. This is due to hormones produced by the placenta to help with the fetal growth and development. These hormones are estrogens, human placental lactogens, growth hormones and cortisol. These interfere with the body using insulin effectively. It collects in the blood instead of being absorbed by the cells. This is called Insulin resistance as already mentioned. Initially the placenta is able to produce more Insulin. But in the end this fails. Insulin resistance becomes high and GDM starts. The risk factor for GDM are previous GDM, BMR over 25 Kg per sqm, family history of Diabetes in the first degree relative (Mother, Father Etc.) poor obstetric history, previous fetal death, polycystic ovarian syndrome, big baby more than 4 Kg in weight, nationality: Chinese, Indian, Pacific Islander and Blacks and many others. The screening is started on the initial visit in these high risk women.

Different centers around the world perform the diagnosis by different technical details and consider slightly different normal values. Generally a glucose tolerance test (OGTT) is done. Blood is taken while fasting, then 75 mg of glucose solution is given to drink in 5 minutes. After this 3 samples of blood are taken for glucose in I hour, 2 hours and 3 hours .These values should be

1, 5.1mmol/L (92mg/dl)

2,10mmol/L (180mg/dl)

3, 8.5mmol/L (53mg/dl)

If any value is above the normal, a diagnosis of GDM is made. This differs in different centers in different places which creates confusion. In the past and in some places these values were slightly different fasting 5.3 mm/l. 2 hours 8.6 moll/L.  One has to go by what the local value and criteria are. Some places recommend two abnormal values, WHO recommends universal screening of all women at 24-28 weeks of pregnancy as currently GDM is increasing in tandem with obesity in the world. This is due to our prosperity and poor life style factors. GDM causes Diabetes type 2, in future years of life. It is recommended to screen for GDM on first antenatal visit if there are risk factors for diabetes These are obesity, BMI more than 25kg per sq. mtrs, family history of first degree relative with diabetes, previous stillbirth, shoulder dystocia, macrosomia baby bigger than 4000gm, ethnicity (Chinese, Indians, African Americans, Hispanic), age older than 35, weight gain of 11lbs since age 18 years.

GDM effects Pregnancy by maternal complications such as high blood pressure, preeclampsia, difficult delivery, need for induction, and caesarian section. It also causes big babies (MACROSOMIA), fetal abnormalities, still birth, shoulder dystocia (difficulty with the delivery of the shoulder) nerve palsies, fractures. These babies have hypoglycemia at birth and hyperbilirubinemia (neonatal Jaundice) these babies grow to be obese and hyperglycemic, develop diabetes later in life.

HOW to deal with GDM

Good management results in good results.  It is worthwhile to involve a diabetic physician a dietitian and may be a midwife. Proper care may, prevents preeclampsia, macrosomia, shoulder dystocia, any fetal injuries, need for induction or caesarian section. One basic rule in women with GDM is never let them go over due dates.

Glucose monitoring

Women should start monitoring fasting and 1- 2hours post prandial blood glucose the values accepted differ, 5.3 mmol/L(latest 5.1). 2hours 6.7 mmole/L.

The simplest treatment starts with life style changes, diet on the advice of a dietitian. Low GI carbohydrates are advised. Regular exercise, walking is best.

One recent  research has suggest that an  active exercise program in  the first trimester of pregnancy including walking, low impact aerobics, stationary bicycle and swimming can reduce the risk of GDM. If life style changes and diet alone cannot change the  blood sugars as desired, then some pharmacological drugs are added. Metformin is one such oral drug .  It is only used in some countries not in most. Insulin is the preferred drug treatment. Insulin is used when diet and exercise does not control diabetes as desired. 0.7 to 1, unit of Insulin is started per kg body weight of the women in question. Half of this dose is given as long acting Insulin last thing at night. The other half is given in three divided dosage as short acting Insulin with three meals, sometimes they can have some hypoglycemia in the middle of the night but it is not frequent or very severe. These dosages are adjusted as need be in each individual woman until the blood sugars are at the desired level as mentioned.

Special fetal care is provided for mothers who have GDM.  This can involve regular fundal height assessment fluid around the baby and fetal heart. This can be assessed by the clinician particularly an experienced one. This is often done by ultrasound as well twice weekly or weekly by biophysical profile from 32-34 weeks on wards. Depending on how well is your GDM is controlled. And if you are on Insulin. This includes fetal heart monitoring as well.  Fetal weight is estimated by ultrasound these days.

The other very important decisions are when and how to deliver this woman. If the GDM is well controlled by diet and exercise they can have a normal birth at term. Do not allow them to go past the due dates. Women are induced between 37-39 weeks if any other complications are present or DGM is not greatly controlled. If the fetal weight assessment is 4500g a caesarean section is advised[AP1] [AP2] [AP3]  they are made aware of limitation of weight assessment, particularly if they have a high BMI themselves.

During labor fetal heart monitoring is done continuously. Mother’s blood sugar is maintained by intravenous glucose and Insulin as required.  A pediatrician is invited to be present for delivery to look after the baby as they can have hypoglycemia or acidosis. Mother’s insulin is often not required after delivery. An OGTT is performed for the mother 6-12 week’s post-partum. Women are advised to breast feed as this is best both for the mother and the baby as it helps with minimizing weight gain. It is best to avoid weight gain and be active as this helps not getting Diabetes in future. An OGTT needs to be performed every year, some say every 3 years which I think is not enough. It is best to avoid too many pregnancies but that is individual choice.

We have very good news for the future, worked out by some great research scientists. They have found that the Tymus gland in our body involved with our immune system has a big role in pregnancy by producing cells called  TREGS via Rank are deficient in women who suffer repeated miscarriages and GDM . They also been trying to use them in clinical trials, so we can get rid of two very big problems in women. Great news.

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CASUSES OF PAIN DURING MENOPAUSAL YEARS

 

Once the periods finish in our later years of life women generally feel very happy. Once you have not had a period for one   year it is called menopause. It is a normal phase in our life cycle, it does mean that we cannot have a pregnancy any more. We feel excited that the menstrual aches and pains will go away, but different types of problems raise their hands, just before the periods completely stop.

In the peri menopausal years, i.e. just before menopause, our periods become erratic due to lack of regular ovulation. When this happens the period that starts after a long cycle is often very heavy and painful. For the control of these irregular periods woman are often given the normal oral contraceptive pill or some special pill which regulates the cycle, stops too much bleeding, stops hot flushes and are also contraceptive, so it is great for relief of this particular situation. The other pain you may continue to have is pain due to migraine. This may be the same as you used to have. It is variable, sometimes it goes away with menopause, or it can start for the first time after menopause. Your GP or Endocrinologist will be able to help. The other important cause of pain is ovarian pains. These could be due to preexisting problems such as residual ovary syndrome after hysterectomy or less often endometriosis, adenomyosis (this is the endometriosis of the uterus) polycystic ovaries. It is nor rare for a cyst to appear de novo in the ovary. The clinicians have to be very careful about these as they can often be cancerous and need proper work up to exclude or confirm this diagnosis.  The extent of treatment will depend on the nature of the cyst.  One very common cause of pain during menopause is what is called fibro myalgia which signifies pain all over our bodies, why we do not know or understand. We live on pain killers, maybe massage and whatever variable treatments. More common causes of pain like in both sexes are different types of arthritis. Women also get some different types of pain due to osteoporosis. This does not cause serious pain except for stress fracture of the spine, or  fractures of the bones, such as hip, and wrist or and  anywhere else such as an ankle. More serious causes of pain are cardiac.   Pain due to cardiovascular disease, venous thrombosis. Never ignore them. One of the commonest cause of death in post-menopausal women is cardiovascular disease. Cardiovascular pain can also imitate shoulder, jaw pain and often stomach pain like an ulcer pain. Please seek medical advice should you feel any of these pains as this requires special investigation. During menopause the immunity decreases that results in infections, these surely cause pain. One such infection at this time is shingles. This is caused if a woman has suffered chickenpox in the past. It appear in the torso like a vesicular rash and is very painful. This is infectious in the air and by symptoms touching.  Until a crust forms on the rash women need to be isolated for ten to fourteen days. Treatment involves pain relief and antiviral such as acyclovir.  If left untreated it can cause fatal complications, such as a stroke, pneumonia, encephalitis (inflammation of the brain). It can also cause blindness if it occurs near the eye.

Management of these pain problems is self-care, exercise, correct diet, humor, group activities, fun, and regular clinical advice.

POST MENOPAUSAL ENDOMETRIOSIS

FREQUENCY, DIAGNOSIS AND MANAGEMENT

Endometriosis a common gynaecological disorder occurring in 5 to 10% of the female population. It is a disease that affects younger women during their fertile life. It is supposed to be oestrogen dependent and therefore subsides after menopause. However it still occurs in 2.5 % of post menopausal women. Now there are millions and millions of postmenopausal women, and thousands are with Endometriosis, thus the gynaecologists often come across them. In recent times management of postmenopausal endometriosis is being considered. There is no clear cut pathogenesis on endometriosis. A very old retrograde menstruation theory does not explain all situations. In some case endometriosis has been seen in some 60 to 70 year old women, without any previous history. These lesions are deep, adhesive and sometimes far off from the pelvis. Besides retrograde menstruation, the other factors can be familial predisposition, genetic and epigenetic factors. It can also happen because of coelomic metaplasia, (meaning the bowel epithelium changes into endometriotic tissue) It can also arise from foetal remnants or abnormal oestrogen production from non ovarian tissues. Perhaps immune deficiency also plays a role it is believed that a hormone called Aromatase can convert the local testosterone into oestrogens and a de novo endometriosis arises. Levels of this hormones are higher in postmenopausal women . This can happen more often in obese women. No single theory can explain endometriosis especially when it happens for the first time. It often happens away from the pelvis on non gonodal (not gonads) such as, organs, kidney, ureter (the tube that connects the kidney to the bladder), appendix and bowel. Very rarely it is even reported on the skin. HRT is often responsible for postmenopausal endometriosis especially if oestrogen only therapy is used. Phytoestrogens (oestrogens from plant sources), these are over the counter drugs and their irregular use can reactivate endometriosis in post menopausal women who had it in younger years. Previous endometriosis can even become malignant if oestrogen only therapy is used in hysterectomised post menopausal women.

When women suffer, with pelvic pain, dyspareunia, Dyschezia (pain on bowel movement), abnormal bleeding, and known to have had endometriosis, has had surgical treatment, even if no history of endometriosis, always keep endometriosis in mind. Now if a woman is still having hot flushes, foggy head, lack of sleep and requests treatment for her problems; what can be offered to help her? After looking at her basic previous history, tests such as, a pelvic examination, cytology basic blood tests, maybe an ultrasound, a laparoscopy, if the pain is significant. If there are any significant findings, such as cysts on the ovary and deep infiltrating endometriosis, surgical treatment is advised. If there are no surgical findings medical treatment can be offered. This can be in the form of oestrogens, progesterone, and modified oestrogens called SERMS (modified oestrogens which act differently on different organs). If she still has her uterus and has recently become postmenopausal, concerned about pregnancy, she can try an oral contraceptive pill. Use a pill that best suits her. She can also try a group of hormones called GnRH analogues (these can lower the sex hormone levels). Tibolone, a synthetic steroid which acts as oestrogen, progesterone and testosterone, is a very useful drug. It helps with hot flushes, decreased libido and is very easy to take. It is a useful HRT for postmenopausal with endometriosis. It has a slightly increase risk of DVT.

Postmenopausal endometriosis is mostly recurrence or continuation of premenopausal endometriosis however there are cases reported which seem to arise new. There pathophysiology is difficult to understand.  Beside the explanations mentioned earlier it is also believed that an inflammatory  small cell protein involved in cell signalling called interlukin  play an important role by allowing ectopic endometrial cells to implant in different places and help them to grow. It is also suggested that stem cells modify as endometrial cells.

Conclusion: - Postmenopausal endometriosis is known to occur in about 2.5% of this group of women. It should always be kept in mind when postmenopausal women present with symptoms of pain and / or abnormal bleeding.

Since the postmenopausal endometriosis can be malignant, they can be surface ovarian cancers, endometrial and clear cell cancers; surgical treatment should be the first line of approach.  Many case reports where endometriosis is seen to occur outside the pelvis, such as the ureter, appendix, and bowel loops, and vagina. In one recent case report on the liver in which after surgical treatment, a SERM (conjugated equine oestrogens/ Bazidoxifene,) was used, as a modified HRT which preventing oestrogen acting on the endometrium (preventing the risk of endomtrial cancer), was used, and endometriosis completely resolved. I wonder if in future others will try to do this. Further research is needed to manage the postmenopausal Endometriosis and guidelines for surgical treatment and different newer HRT, will also be very welcome.

BOY OR GIRL? IT DEPENDS ON THE MALE PARTNER

This story starts in 1962. I was a very young doctor, just started a new job at a newly opened Medical school as a lecturer. It was my very first day, at my first job after completing my training. Those days there was no ultrasound, not even an x-ray machine nearby. My registrar called me to this new admission in the labour ward a woman was in established labour, who had never seen a doctor throughout her entire pregnancy. She had an enormous belly. It was difficult to feel anything. I expected it to be a twin pregnancy with too much fluid. We had no idea about her blood count. She told us she is trying for a male child and already has six daughters .Within minutes of her arrival the first child was born, the second child was already in a big hurry to arrive in the world , her belly was still somewhat biggish, however I gave her the injections to prevent bleeding which  is given after twin birth, then suddenly I realised that there was another baby, I had never witnessed  a triplet birth and never thought of it, we rushed a bit, to save getting  this baby trapped  after the injection, but luckily this baby arrived safely. Guess what, all the babies were girls well formed all normal with good weights between 4.5 lbs to 5 lbs. I suddenly felt very sad. I did not know how to tell the parents I told them of a family who had 8 daughters hoping for a son one day they all became very successful doctors. Here with this lower middle class family I was worried about their feeding and schooling.  60 years on, since I still think of what happened to them. In some countries there is such a fanaticism about having a son to carry the family name. Sadly the women are always blamed however it is the fathers Y chromosome which is responsible for the sex of the baby. In humans there are two sex chromosomes X and Y. The females have XX and male are XY. When a baby is being formed, an X chromosome comes from the mother and Y from the father, if there is a Y chromosome then the baby will be male. There is a 50 /50 chance in nature what will happen.  There are a few theories. The sperm can be male or female depending on what a particular man has inherited. The male are divided as mm, mf, and ff, men with mm sperm will mostly have boys and ff will mostly have girls. This varies in different generations.  The female sperm is longer stronger and also lives longer so a few theories were suggested that if you want to have a female child work out your ovulation and refrain from having sex two to three days before that, by the time you ovulate your male sperms may have demised, and if you want a male child have sex as close to ovulation as possible the fast running sperm will be able to fertilize the egg. In the 21^st century ovulation can be worked out by temperature charts, and ultrasounds, even an artificial inoculation of sperm can be done on the precise day. This in my very brief experience proved excellent. In more sophisticated medical situations where sexing is required for prevention of sex linked diseases, a micro sort system is recommended in preference to per implantation biopsy and intra villous sampling. Stories also go about what position you adopt during sex for a boy or girl. Inherited billionaires have more boys. People who have more brothers have more sons and vice versa. How do we guess in modern times when everybody has only one or two siblings? To my way of thinking the ovulation technique seems more scientific. Poor King Henry the VIII was not aware of any of this, and that it was he who was responsible for the sex of his child and not his queens.

INTERSTITIAL CYSTITIS (IC) OR PAINFUL BLADDER SYNDROME

This is a poorly understood condition, which millions of people suffer from around the world. Two thirds of these are women.  Here we will focus mainly on women. They suffer from pain in the bladder area (that is why it is also called bladder pain syndrome or BPS). There is pain in the inner thighs, back ache, chronic pelvic pain, pain on passing urine, need to pass urine frequently without much urine in the bladder. There is no bladder infection. The problem must be going on from 6 weeks to 6 months. The Bladder is the bag where the urine collects from the kidneys, when it is full the brain sends a message to pass urine. Normally it is not painful; except when there is a bladder infection. However IC or BPS the frequency of going to the toilet 50 – 60 times during a 24hr period, middle of meetings or odd times makes sex life distorted, due to exaggeration of symptoms for several days following sex.  Even more pain during menstruation and any kind of stress, acidic type of food, strawberries, lemons, oranges, coffee, and chocolate.  It is commonly believed that cranberry juice helps urinary symptoms but in fact it makes IC worse all this makes life very difficult for women. There are many conditions, which cause symptoms similar to IC that women suffer with and some of these are Irritable bowel syndrome, Endometriosis, Sexually transmitted infections, kidney disease, bladder cancer or stone, chronic fatigue, fibromyalgia, multiple sclerosis, emotional behavioural and sexual dysfunction consequences.  Many of these are quite serious. What causes IC is not understood. There is some genetic predisposition, female sex, fair skin, red hair, chronic pain disorders, some kind of autoimmune problem (that is when the body attacks itself). Can it be Hormonal, as it is more common in females?  Is this a viral or unknown infection?  There are defects  seen in the bladder mucosa, it is not  clear, if it is the cause or the result of the disease, a leak  from these  areas  irritates the bladder by the substances in the urine.

Many researchers believe that a substance called, antiproliferative factor (Substance that can interfere with healing, APF) found in the urine of people, with IC hinders the healing of the damaged mucosa of the bladder. In fact these researchers are seeking to use APF as a biomarker for IC. Many other conditions need to be excluded before we start thinking of IC. Some of these are, as already mentioned others can be radiation treatment, drugs that may have caused allergy to the bladder, pelvic floor disorders, damage or entrapment of pelvic nerves, vulvodynia, (pain in the vulval area without any obvious infection or skin disease) prolapse of pelvic organs, vulval or vaginal or cervical pathology, pelvic masses such as ovarian disease, and trigger points causing pain tenderness and muscle spasm.  

For making a diagnosis history is very important. It must be going on for 6 weeks to 6 months, take a family history, any radiation any drugs or any other problems. It is most important to exclude any bladder infection at present and during this time. Do a urine culture and urine cytology, this will exclude any infection or cancer cells. A clinical pelvic examination can exclude any prolapse, vaginal, vulval, uterine and often ovarian pathology.  In IC the bladder base is tender on an internal examination. Another test that is that can be performed is called Urodynamics. This can measure the bladder pressure and its capacity, women with IC start feeling the pain very soon after it starts to fill and get a desire to pass urine. The other test that is done by a few   doctors but not recommended by everyone is a Potassium solution test. In this test, water is used to fill the bladder followed by a potassium solution and in women with IC; filling with potassium solution is very painful. The other test called a Cystoscopy needs to be done by a specialist gynaecologist, urologist or urogynaecologist. In this test the bladder is instilled with fluid and then examined by a Fibroptic light with a Telescope. 

This shows petechial haemorrhages in the bladder wall (small pinpoint bleeding, also called Glomerulations) in different quadrants of the bladder, reddened mucosa, submucosal bleeding, and mucosal disruption, oedema with or without bleeding. This is diagnostic of some forms of IC. Depending on these finding IC is classified into four grades. Then, there are striking reddened patches on the bladder wall called Hunners ulcers. 

This finding also suggests another type of IC. Hunners areas, decreases the bladder capacity due to fibrosis and is more distressing than the one with minute haemorrhages.  A bladder biopsy is taken from these ulcers; this shows inflammation, mast cells that can cause severe allergic reaction, fibrosis and granulation. There is a questionnaire about pelvic pain frequency (PPF) and urgency of micturition which is filled by the client and if the score is 10 or more it is in favour of IC. It has been shown that the Clinicians under diagnose IC by a large percentage because they do not always think of IC in women suffering from chronic pelvic pain.
This  is  difficult  to  understand  what  causes  all  these  problems? The main question is; what is the solution? This depends on the age, severity, and how much stress is it causing and interfering with the quality of life.  

For a start, self help is required, stop the trigger factors, stress, foods that upset IC, smoking, meditation, yoga, planned breaks for toilet, gentle stretching exercises and restrict drinks before bed time. Physiotherapy for pelvic floor muscles, psychotherapy, proper bladder retraining.  Some drugs such as simple paracetamol, non steroidal anti inflammatory drugs (NSAIDS), antihistamines (anti allergy drugs) and antidepressants have all   been tried. Some tablets that help to relax the bladder are tried in more serious cases

There is one special tablet called, Pentosan Polysulphate Sodium which is an oral medication which is tried in many clinics. It takes 2-6 months to help.  Pain relief takes the longest time .First it is tried for 3 months and then for further 3 months. Its side effects are minimal nausea, headaches, dyspepsia and liver dysfunction, these are all reversible. They probably act by mast cell deregulation, immunological and neurological effects. These down regulate the activity of the sensory fibres that take the pain sensation to the brain. There are also drugs that are instilled into the bladder weekly for 6-8 weeks and then 2-5 weeks to relieve the pain and relax the bladder for three months. These are called Dimetylsulfoxide (DMSO). Some clinicians mix Heparin and Lidocaine( a local anaesthetic) for better relief of symptoms. Nerve stimulation technique is also tried by a Tens Machine, or Sacral Nerve Stimulation by a device similar to a Pacemaker called InterStim.

In some cases surgery is tried by electro  cautery or laser for  the bladder ulcers, resection of  the  abnormal area, Sub mucosal   injection. In rare situations enlarging the bladder size by using the gut is performed, but this does not help with pain. Extremely rare situations bladder is replaced by a bowel loop. There are many such techniques; this requires very special surgeons and special care of the urinary diverted loops or opening stoma. On a simpler front acupuncture and herbal remedies are tried.

Interstitial cystitis is a very stressful condition which mainly affects women causing pain, urgency and frequency of micturition in absence of any infection of the blabber or any other discernible pathology. There is no definitive treatment for IC. It cannot be cured. A combination of treatments goes a long way to relieve symptoms. Treatment is generally started in simple ways.  Progressively more and more complicated procedures are performed to help a very distressed woman.

PELVIC ORGAN PROLAPSE (POP)

Pelvic organ prolapse simply means that the pelvic organs descend into the vagina. This includes bladder (cystocele ) rectum (rectocele), uterus and bowel (enterocele ). All of these are not seen all the time in the same person, different combinations of POP is present in different women. It is also classified in degrees depending how far down it has come , when it is a bit in the vagina it is first degree , when it is at the opening of the vagina it is second degree, when it is outside it is called third degree, when it hangs totally outside it is called procendentia .

Globally one in five female suffers from it. However women do not complain about it, perhaps they are embarrassed about it and do not know that it can be treated. In developing countries almost 50% of women suffer due to difficult child birth at home. The main cause of POP is child birth, chronic cough, smoking, constipation, obesity, and hormone deficiency at during and after menopause. It can be occupational due to standing too long and heavy lifting all the time. POP in women who have never had a child is very rare; it is usually due to developmental defects either in the pelvis or the spine. Women who have POP also suffer from urinary problems such as leakage of urine (incontinence) and even faeces.

The symptoms women experience is a feeling of pressure in the vagina and with a finger they can feel a lump. Other symptoms are, pain on standing, backache, belly ache, difficult sex, urinary and bowel problems. Often in very severe cases the pelvic organs constantly hang out. Treatment can be started very soon after child birth with pelvic floor muscle exercises. In fact in many places when maternal health is taken seriously they are taught to the mother at the time of discharge. The most common is called Kegal exercise which has been going on for generations.  Perhaps some women may remember being told about it, when they had their baby. Changes in life style factors is also important,  such as avoiding constipation, smoking,  being overweight, proper eating habits, use of oestrogens if women are in the menopausal age group.  The other non surgical treatment is pessaries.

These help to keep the pelvic organs pushed inside.  They need to be changed every three to six months. Sometimes the women can do it themselves but it is best if a clinician can do it, so that they can look for any infection, ulceration and can do cervical smear when required. This treatment is ok when the women do not wish for operative treatment or are unfit for it or often too old.

Operative Treatment

This depends on several factors; how old is the women, what is the actual problem, for example a cystocele and what else, most importantly is the preservation of the uterus required or is it a nulliparous POP? (This means a woman has never had a child). The operations are cystocele and, rectocele repair or both and repair for descending cervix.  If it is a nulliparae’s prolapse the cervix is lifted up by different types of sling operation, hitching it to sacral promontory of the spine. These were invented by Indian gynaecologists as this is common in India.

Some other sling operations are also performed if there are urinary and bowel problems. I will discuss these in my next blog. Side effects of these operations are they can recur in 20-30% of women, especially after a child birth and soon after repair, or a POP can come up in another place. If the rectocele repair becomes tight it causes painful sex and bowel problems. In older women when preservation of uterus is not desired a vaginal hysterectomy with the repair for other defects is performed. Following these operations a catheter is left in the urinary bladder while the tissues heal.  Women are usually in hospital for 2-5 days.

One very last operation is the total vaginal fusion. This is done when intercourse is never desired and the uterus is absent. A slightly modified operation called La forts operation was once performed in 1877 and then it sort of died out.  Now it is coming back as women are living longer. This is a very simple operation with a success rate of 90%.  It can be performed under local anaesthesia. Hospital stay of 2 -3days, hardly any complication rate and satisfaction rate of women is very high. With changing demographic this is more often required.

POP is a big subject now so much so that it has become a separate speciality within the field of gynaecology. There should   be more public awareness so that the women are not hesitant to ask for help in early stages of POP problems.

ADENOMYOSIS: ENDOMETRIOSIS OF THE UTERUS

Eva is 37 years of age has 2 children; 6 and 4. For many months she had been having very heavy and painful periods. She was unable to cope with her day to day life; her quality of life was getting progressively worse. She went to see her GP, and complained to him about all her problems. He asked her if she had any difficulty with her bowel and urination, she immediately answered yes. I have pain both on urinating and bowel action and also frequency of passing urination. When the GP examined her he noticed that she was looking pale, he could feel her enlarged uterus on abdominal examination and confirmed this on pelvic examination, that it was about the size of 12 -14 weeks of pregnancy it was hard and tender. The uterine size is expressed with reference to the size of pregnancy; however during pregnancy it is soft. He did her haemoglobin, this was low 9.6gm (Normally it is about 11-12). He was an experienced GP, and gave her a diagnosis of a uterine Fibroid or a condition called Adenomyosis.

Adenomyosis is a condition in which the endometrial cells grow within the uterine muscle layers. It can be scattered in the muscle or form a mass like effect, unlike fibroids it does not have a capsule or an outer cover. It is believed that it affects up to 65% of females in their life time. A few decades ago it was thought that it does not affect young women who have had no children. Recently with the improvement in diagnosing Adenomyosis (ADENO) with Ultrasound and MRI it is believed that 35% of women suffering from ADENO are nulliparae’s (women who have never had a pregnancy), in fact in English medical literature some cases had been reported in adolescent girls. One third of the females suffering from ADENO have no symptoms. Others suffer from heavy painful menstrual periods, lower abdominal pain, and pain on intercourse, passing urine and on bowel actions. It also causes infertility, miscarriages and even premature birth. If associated with polycystic ovarian syndrome it is even worse due to high oestrogen levels. This makes IVF difficult due to altered uterine shape, uterine peristalsis, and makes embryo implantation difficult; a toxic and altered hormonal environment makes it further worse.

One problem is that it is a long disease, which lasts for years almost up to menopause. It often becomes mild after menopause or goes away. I have removed some very enlarged painful uteri, in post menopausal women.   A patient’s medical history and a clinical pelvic examination give a good clue to its diagnosis. Blood tests can be done to assess a woman’s condition. New high resolution ultrasound and MRI give a precise diagnosis. MRI is an expensive test and not always available ultrasound is nearly as good. In recent times it has been advised to always keep AENO in mind if you have a young adolescent girl with intractable pain and painful period, please do an ultrasound.

Why does ADENO happen? It can be due to trauma to the myometrial and endometrial zone during child birth, an operation such as curettage, caesarean, this is a process of tissue injury repair. The endometrium invades into the myometrium.  The other theory is that, stem or embryonic cells change into endometrial cells and make these endometrial nests or even masses.

The treatment of ADENO initially conservative especially if the woman is young and fertility is an issue.  Antinflamatory tablets are given during periods so that they help pain and excessive bleeding, its effect are minimal to moderate. Next in the line of treatment are hormones, they are either given to make the periods milder or stop them completely.  They all have their side effects and most of them stop fertility, however the good thing is that all of them are temporary.  Let’s start from oral contraceptive pills, then progesterone tablets or injections and vaginal rings. These also give Adenomyosis time to heal, but how much it does; we do not know.  When they are stopped the problem starts again. Another treatment is a progesterone implant a small rod implanted in your upper arm under the skin it lives there for 3 years. It can cause some irregular spotting, prevents pregnancy.  One of the good hormone is Danazol tablets, or danazol loaded intrauterine device which fitted in your uterus for 6 months.  This has a great advantage that a woman can still achieve a pregnancy while she is using this.  A strong hormone treatment is Gonnadotrophin releasing Hormone (GnRH). This is given as an injection every at 1 to 3 monthly intervals. This suppresses our pituitary gland, thus our ovaries, hence no more periods. This cannot be a very long term treatment; it causes side effects like menopause. Add on treatments are given for these.  One serious side effect is the loss of bone density. In contrast to this, a group of drugs called Aromatase inhibitors which stop the formation of oestrogens in the body from other hormones that exist in the body fat. They are also found to be useful particularly in obese women where extra oestrogen is formed in the body fat. GnRH is unable to do this.

An present an intrauterine device containing Levonorgestal is found to be the best reversible treatment of Adeno. It prevents fertility and can be used repeatedly, after every 3-5 years.  The failure rate of treating symptoms is only 20 percent. There is a smaller IUD now available and can be tried in adolescents. Local excision of adenomyosis has been tried, but it is not easy and long term results are a bit questionable and unsatisfactory. The treatment of ADENO depends on, if fertility is to be preserved. Hysterectomy is the best treatment, although uterine artery embolization and endometrial ablation is also tried with some success.  As long as a patient agrees to surgery, a hysterectomy can be performed abdominally, vaginally or laparascopically and now even robotically.

Generally ovaries do not need to be removed.  In some very difficult cases it is found to spread into the bladder and bowel.

Adenomyosis is a difficult and painful condition from which women used to suffer a lot in the past, but the new techniques of diagnosis and treatment have helped the gynaecologist in its management.