Gynaecology

Amenorrhea is the medical term for not having a period and is diagnosed as one of two types of amenorrhea: primary and secondary amenorrhea.

Primary amenorrhea is typically diagnosed when a female’s period has not started by the age of 14 years and there are no signs of other sexual developments such as public hair or breast growth. It may also be diagnosed if periods have not started by 16 years but sexual development has begun.

The most common cause of primary amenorrhea is Turner’s Syndrome, but it can also be caused by other factors including:

• Müllerian Agenesis (an underdeveloped vagina with or without the uterus)
• Delayed puberty (usually associated with an acute or chronic illness)
• Polycystic Ovarian Syndrome
• Hypothalamic amenorrhea (related to eating disorders)
• Congenital disorders and birth defects
• Enzyme deficiencies
• Pituitary tumours
• Hypothyroidism
• Excessive exercise (usually associated with elite athletes)
• Excessive stress

Secondary amenorrhea is diagnosed when periods have started but then stopped for approximately three months or more.

The causes for secondary amenorrhea include:

• Severe emotional stress
• Extreme weight loss, eating disorders or nutritional deficiencies (often associated with other medical conditions)
• Extreme exercise (including elite athletes)
• Medication side effects
• Medical conditions relating to the Endocrine system
• Hormonal imbalances (Hyperandrogenaemia or Hyperprolactinaemia)
• Early menopause (low levels of oestrogen)

How do you diagnose amenorrhea?

A number of tests can be used to diagnose the cause of amenorrhoea and include urine or blood tests, checks of hormonal levels and ultrasounds. Depending on medical history and contraception being used, a number of different types of tests may be required.

What is the course of treatment for amenorrhea?

Once the tests have been completed, we are able to prepare a course of treatment for amenorrhea. Each case will be different and depending on the cause, may require medication, adjustment of exercise regimes to reduce weight (or encourage weight gain) and dietary changes.

In some cases, we may suggest using hormone therapy (the combined oral contraceptive pill) which will usually cause regular periods to return, but unfortunately it will not treat any underlying causes.

Gynaecological cancers can affect many parts of the reproductive system including the ovaries, cervix, uterus, vagina, vulva, and fallopian tubes.

Some cancers can be screened using tests while others often go undetected as there is no test available. While ongoing research and development is underway it is vitally important that women learn to be aware of their body and to recognise the possible changes, signs and symptoms of the various gynaecological conditions.

If you are concerned with the changes to your body, it is recommended that you visit your GP, undertake some preliminary testing and obtain a referral to a gynaecologist.

Once we receive the results from the preliminary testing, we can undertake further investigation to make a diagnosis and recommend a course of treatment.

A colposcopy is an advanced screening option when a standard pap smear provides evidence of abnormal cells on the cervix.

Undertaken in our private medical suite, a colposcopy is a relatively quick procedure done under a local anaesthetic. Small biopsies of the cervix are taken for laboratory testing to reveal the types of abnormal cells present.

Some discomfort (like cramping) is usually felt up to 24 hours after the procedure with minor bleeding or spotting common.

There are various reasons why women may need to use contraception. The most common reason is to prevent pregnancy, but it might also be recommended to treat particular medical conditions (such as hormonal imbalances and amenorrhoea).

There are a number of different types of contraception available but it important to consider a range of factors when deciding which option is the best for you.

Combined contraceptive pill
Otherwise known as ‘the pill’, the combined contraceptive pill, is made with synthetic versions of the female hormones oestrogen and progesterone. It is usually taken to prevent pregnancy but may also be prescribed to treat other conditions including:

• Painful and/or heavy periods
• Premenstrual syndrome
• Endometriosis (tissue growing on the outside of the uterus)

Progestogen-only contraceptive pill
For women who are unable to use the combined contraceptive pill, we may prescribe the progestogen-only pill which doesn’t contain any oestrogen (more suitable for women over the age of 35 or who smoke).

Contraceptive implants and injections
A convenient and effective form of contraception, implants and injections are very reliable in preventing pregnancy. Both options are long-lasting, reversible and progestogen-only methods of contraception.

Mirena
The Mirena is a plastic T-shaped device that is inserted into the uterus. It contains synthetic progestogen (naturally made by the ovaries) which allows a slow release of the hormone into the uterus.

Typically providing 5 years of contraception, Mirena is 99% effective in preventing pregnancy.

Implants
An alternative to Mirena, a contraceptive implant is a small thin flexible rod approximately 4cm long and contains progestogen, a hormone that is slowly released to prevent pregnancy.

The rod is inserted (and later removed from) under the skin on the inside of the arm by a qualified health professional.

Lasting up to 3 years, the implant is an easy and cost-effective contraceptive option for women.

Injection
Given into the arm or buttocks muscle every 12 weeks, the contraceptive injection is also a very effective (94 to 99.8%) option.

The injection is made with synthetic progestogen and works by thickening the fluid at the entrance to the uterus which stops sperm from entering. The synthetic hormone also thins the lining of the uterus so that potentially fertilised eggs are unable to attach to the uterine wall.

An endometrial ablation is a surgical procedure to remove the lining (endometrium) of your uterus. This procedure would be recommended for women who are experiencing heavy and painful periods and have not had success with medication or contraceptive options such as Mirena or contraceptive implants. This operation is not recommended for women who still want children.

In most cases, the operation takes about 30 minutes and is conducted under a general anaesthetic (alternative anaesthetic techniques are possible).

The procedure involves an examination of the vagina before a small, specialised telescope is passed through your vagina, across your cervix and into the uterus.

Fluid is fed through the telescope to swell the uterus before a diathermy resecting loop (a loop of wire heated by electricity) is used to remove the lining of your uterus and any polyps or small fibroids they find. Another modern way of doing it is by using a radiofrequency device called ‘Novasure’.

What complications are associated with an endometrial ablation? 
As with all medical procedures, the risk of complications is present and can include:

• Pain
• Feeling or being sick
• Bleeding or discharge
• Infection
• Allergic reaction to the equipment, materials or medication
• Blood clot in your leg
• Blood clot in your lung
• Specific early complications
• A small hole in your womb made by one of the instruments, with possible damage to a nearby structure

Bleeding during the operation

• Fluid overload
• Failed procedure
• Specific late complications
• Haematometra – where blood and other menstrual fluid collect in pockets in the uterus
• Blood and fluid collecting in your fallopian tubes
• Continued bleeding or pain

How soon will I recover from an endometrial ablation?
The procedure is done as day surgery and so you will be discharged the same day. Most women return to normal activities after 2 or so days and then are fit for work after 7 days. It is common to have bleeding or discharge for up to 4 weeks after the procedure.

Endometriosis is a relatively common medical condition in women. Cells similar to those of the uterus lining grow in other parts of the body (mainly outside the uterus) leading to inflammation and scarring which can cause adhesions or organs sticking together.

This chronic condition is progressive, painful and can affect female fertility as well as participation in work, education or sporting activities. At this point there is no cure for endometriosis which can last beyond menopause.

If diagnosed with endometriosis we work with you to develop a treatment plan to help manage the symptoms and pain.

What are the symptoms of endometriosis?
Each case of endometriosis is as different as the woman presenting with the condition. Some may have severe symptoms while others will experience mild or no symptoms.

Common symptoms include:

• Severe abdominal or pelvic pain before and during a period, during or after sex or when going to the toilet
• Heavy and extended periods or irregular bleeding, sometimes with clots
• Changes in urination or bowel movements, such as bleeding or needing to urinate more frequently
• Feeling bloated (with or without pain)
• Fatigue around time of period
• Experiencing anxiety or depression related to the pain
• Infertility issues.

What causes endometriosis?
While the causes of endometriosis are unknown, research has indicated certain risk factors may lead to the greater likelihood of developing this condition. These include:

• Retrograde menstruation – menstrual (period) blood travels back through the fallopian tubes and into the pelvis causing the endometrial cells to stick to the pelvis or other organs
• Metaplasia – when regular pelvic tissue changes into endometriosis
• Long and heavy periods
• Frequent periods or short cycles
• Period starting before aged 11
• First pregnancy at a mature age
• Issues with the immune system
• Low body weight
• Alcohol use

Typically, there are 4 stages or grades of endometriosis

Stage/grade I (mild)
Small patches of endometriosis scattered around inside the pelvis.

Stage/grade 2 and 3 (moderate)
Tissue is widespread and can be found on the ovaries and other parts of the pelvis and often with significant scarring and adhesions.

Stage/grade 4 (severe)
The tissue has spread to most of the pelvic organs and presents with sever scarring and adhesions.

How is endometriosis diagnosed?
Endometriosis is commonly diagnosed when women are seeking medical advice due to infertility or during a procedure for another medical condition. Routine questions such as symptoms and period cycles may help to determine if you require an investigative procedure called a Laparoscopy that allows gynaecologists to search for tissue in the abdomen and conduct a biopsy for pathology confirmation.

How is endometriosis treated?
Several factors influence how we treat endometriosis. Looking at the severity of the condition, the likelihood of wanting to conceive and previous history with contraceptive medications, we will create a treatment plan to suit you and your needs.

In most cases we can treat the symptoms with medication, surgery or with the use of in utero devices (IUDs) such as Mirena.

Where surgery is recommended, we remove as much of the endometriosis tissue possible through a procedure known as a laparoscopy. A small cut is made in the abdomen to examine and remove the tissue.

In severe cases, a full hysterectomy may be required.

Most women with endometriosis can become pregnant without medical intervention but some women will have trouble with fertility. During your consultation at Ritu Rana Medical we can discuss your fertility options to provide the best possible chance of conceiving.

Fibroids, or Myomas, are growths (benign tumours) of various sizes that can form inside the wall of the uterus. Most women who have fibroids do not experience any symptoms and are often discovered during other tests or investigations.

They are occasionally associated with infertility, premature labour and miscarriage and can cause heavy, painful periods.

While we don’t know why fibroids grow, we understand that female sex hormones oestrogen and progesterone have some role in their development.

What are the symptoms of fibroids?

While most women do not experience symptoms from fibroids, those who do may have:

• Heavy and painful periods
• Spotting (bleeding) between periods
• Painful intercourse
• The feeling of heaviness or pressure in the back, bowel and bladder
• The need to urinate often
• A lump or swelling in the lower abdomen.

What are the complications of fibroids?
Women who have fibroids may experience complications, including:

Anaemia
With excessive menstrual blood loss women can develop anaemia or low iron which can leave them experiencing breathlessness, fatigue, paleness and reduced exercise tolerance or exercise intolerance.

Urinary issues
Some women with large fibroids can feel like their bladder is full, uncomfortable and like they need to urinate often. Large fibroids distend the uterus and place pressure on the bladder.

Infertility
In some cases, women may experience infertility if fibroids are present in the uterus. The fertilised egg may be unable to implant properly to the uterine wall or it may try to attach itself to a fibroid which will not allow the egg to develop.

Miscarriage & Premature Delivery
Large fibroids can interfere with blood flow to the placenta or take up space within the uterus which ultimately affects the developing baby.

How are fibroids diagnosed?
Most fibroids can be detected using ultrasound technology which is quick, painless and less intrusive.
For further in-depth investigation a hysteroscopy may be recommended. A camera and light attached to a thin telescope (called a hysteroscope) is passed through the cervix to view the uterus.

What are the treatment options for fibroids?
Many women will not require treatment for fibroids as they don’t necessarily feel any pain or even know they have them. In these cases we will monitor for any changes.

For women who do require treatment, it will depend on the number of growths, the size and where they are located.

Treatment options can include:

• Medication to shrink growths
• MRI-directed ultrasound
• Arterial Embolisation
• Hysteroscopy
• Laparoscopy
• Open surgery
• Hysterectomy

A gynaecological ultrasound is just one of the tests we may need to use to help determine a medical condition and the best treatment option. There are two types of gynaecological ultrasound used:

Abdominal ultrasound
This procedure is conducted on the stomach region where a handheld probe is run over the abdomen.

Vaginal ultrasound
A thin probe is inserted to scan the internal organs. It is not usually painful but can be slightly uncomfortable.

Gynaecological ultrasounds help provide a better idea of what is happening with the reproductive organs without the need for invasive surgery. We recommend a gynaecological ultrasound if we are investigating issues such as:

• Heavy or painful periods
• Bleeding between periods
• Bleeding after menopause
• Delay in getting pregnant
• Lack of periods
• Pelvic pain
• Masses or cysts
• Risk of cancer
• Suspicion of different anatomy
• Particular diseases or hormone patterns.

At Ritu Rana Medical we can conduct gynaecological ultrasounds conveniently in our practice using the latest medical technology.

Some medical conditions may require a hysterectomy which is a major surgery to remove the uterus and, in some cases, the cervix, fallopian tubes and ovaries. Patients who undergo a hysterectomy will be unable to become pregnant so this must be taken into consideration.

Typically, this operation may be advised for a number of medical conditions where other treatment options may not have been successful. These conditions include the diagnosis of:

• Cancer of the uterus, cervix, fallopian tubes or an ovary
• Heavy menstrual bleeding (after other unsuccessful treatments options)
• An enlarged uterus that is pressing on other organs
• Fibroids within the uterus (if causing issues)
• A prolapsed uterus
• Severe chronic pelvic pain (after other unsuccessful treatment options)
• Endometriosis — when the lining of the uterus grows outside the uterus
• Pelvic inflammatory disease
• Adenomyosis (when the cells that normally line the uterus also grow in the layer of muscle in the wall of the uterus).

Once we have confirmed that a hysterectomy is the best treatment, we book the procedure at the Mater Private Suites (with an overnight stay) and discuss your treatment plan.

In the few weeks following the procedure it is common to have vaginal bleeding and discharge. If you are concerned by excessive bleeding or notice any significant changes following your procedure, we recommend giving the clinic a call to discuss.

We understand that the decision to have a hysterectomy can be a very emotional one for some women and we encourage you to discuss this during your consultations. We are focused on you, the patient, and your wellbeing.

Strenuous activity and the lifting of heavy objects will not be possible for 4 to 6 weeks. We also recommend you prepare for time off work for between 2 to 6 weeks. It is important you allow your body the adequate time to rest and recover following this type of surgery.

As with all procedures, please contact the clinic if your pain worsens or if you develop abnormal redness, pain, swelling of the wound, a bad smelling discharge or continuous heavy bleeding.

This procedure is undertaken at the Mater Hospital and typically requires a 2-night hospital stay.

A hysteroscopy if an investigative procedure where we look inside the uterus using a thin, telescope-like instrument. It can help to diagnose medical issues within the uterus.

Why do I need a hysteroscopy?
We may recommend a hysteroscopy if you are experiencing certain symptoms such as heavy periods and abnormal bleeding, fibroids or polyps and an ultrasound hasn’t provided enough information to form a diagnosis.

Is this done under anaesthetic?
The hysteroscopy procedure can be undertaken at the Ritu Rana Medical suite and is usually performed under a local anaesthetic. In some cases, we may recommend the operation to be performed under a general anaesthetic which will be discussed during your consultation.

It is common for some women to experience ongoing, heavy menstrual bleeding which can be painful and inconvenient. Some of the most common reasons for heavy menstrual bleeding include fibroids and polyps.

To investigate the underlying reasons for this bleeding we can undertake a range of tests within our clinic.

Once a proper diagnosis is made, we work with you to create an appropriate treatment plan.

Menopause is typically the end of women’s menstruation when the ovaries no longer produce oestrogen and stop releasing mature eggs. The end of a woman’s reproductive era can be quite challenging with the inconsistency of periods, changes to cycles and the numerous uncomfortable symptoms before and after.

Common symptoms of menopause include:

• Hot flushes
• Ongoing vaginal and bladder infections
• Urinary incontinence
• Insomnia and poor sleep
• A noticeable reduction in sex drive
• Significant mood swings
• Vaginal dryness
• Heart palpitations
• Abnormal hair loss or growth.

If you’re experiencing perimenopause, (the early stages of menopause) or believe you are further along in the transition process you may require some assistance.

To assess where you are in the menopausal process, we recommend speaking with your GP who may run some initial tests before referring you to our clinic for further assessment. Once we have all test results and can confirm the symptoms are menopause, we can work with you to discuss a treatment plan. This may include Hormone Replacement Therapy (HRT) or other treatment and lifestyle options.

Hormone Replacement Therapy has provided numerous beneficial results for women experiencing menopause but, as with all medication, there can be side effects. When discussing your treatment plan, we work through your previous medical history, any potential reactions to medications and how to manage side effects should they arise.

We encourage open and honest conversations about your health, so if you’re concerned about HRT, the side effects or any of the medical procedures, please discuss them. Patient health and wellbeing is our top priority.

Pelvic pain refers to any pain related to the pelvic region. The reasons for pelvic pain can be varied and persistent or temporary (coming and going with periods) and is reported to affect 1 in 5 women.

To diagnose the potential causes of your pelvic pain, we recommend visiting your GP who may refer you to our clinic. We use a number of investigative procedures to determine the underlying cause of pelvic pain including:

• Monitoring pain levels over the period cycle
• Vaginal ultrasound
• Laparoscopy
• Blood tests.

Some of the common gynaecological causes of chronic pelvic pain are:

• Pelvic endometriosis
• Adenomyosis of uterus
• Large uterine fibroid
• Ovarian cyst (large)
• Gynaecological cancers.

What is the difference between Polycystic ovaries and Polycystic Ovary Syndrome?
Polycystic ovaries are when the ovaries have cysts on the partially formed follicles that contain an egg. This condition can be extremely painful for women and can contribute to infertility issues.

Polycystic Ovary Syndrome (PCOS) is a hormonal condition that produces an extensive range of symptoms from excessive facial and body hair, irregular menstrual cycles, acne, obesity, complications with fertility and potentially, diabetes.

Even though many women may have polycystic ovaries, not all of these women will have PCOS. To obtain an accurate diagnosis of PCOS you will need to obtain a referral to a gynaecologist for appropriate testing.

How do you diagnose PCOS?
In our initial consultation we may use various methods to confirm a diagnosis of PCOS including:

• Blood tests
• Pelvic or vaginal ultrasound
• Examination of medical & family history

How do you treat Polycystic Ovaries and PCOS?
The treatment options for Polycystic ovaries and PCOS will depend on the severity and the symptoms being experienced. In many cases, we can effectively treat PCOS with medication and lifestyle changes (weight reduction, regular exercise).

Some women with PCOS may find it difficult to get pregnant. We can assist with this usually with the help of some medications or injections. To find out more, please book an appointment with Ritu Rana Medical.

Spotting or bleeding 12 months after your last period (menopause) is not normal and should be investigated to rule out serious medical issues. In most cases, investigations of postmenopausal bleeding or spotting indicate a simple medical condition that can be easily treated. In other cases, however, this bleeding is indicative of something more severe such as gynaecological cancer that may require ongoing treatment or surgery.

If you’re experiencing postmenopausal bleeding, we recommend visiting your GP to obtain a referral to our clinic. Your doctor may suggest conducting blood tests which will assist in finding a potential cause.

Blood tests, in conjunction with a pelvic ultrasound and discussion around your medical history, will provide a comprehensive picture of what may be occurring to then determine the best course of treatment for the bleeding.

Women’s bodies are amazing – they have the potential to create and grow new life but with these wonderful capabilities also comes the risk of complications for our bodies after giving birth or once our reproductive cycles are complete.

What is prolapse?
Prolapse is common when the ligaments and muscles in the pelvic region become stretched, causing the organs to drop down out of their proper place. There are four main types of prolapse including:

• Vaginal prolapse – the walls of the vagina are overstretched and hang towards the vaginal opening
• Uterine prolapse – the uterus and cervix drop down through the vaginal opening
• Bladder prolapse – the bladder causes bulging in the vaginal wall usually due to the weakening of the pelvic floor muscles
• Bowel prolapse – the bowel bulges forward into the rear of the vaginal wall.

Apart from pregnancy and childbirth there are a number of other causes for prolapses. These include straining when going to the toilet, the consistent heavy lifting without proper abdominal support (can be children, weights or other heavy objects), excessive weight, smoking and chronic lung diseases with coughing, women who may have already had pelvic surgery and post menopause.

What are the treatment options for prolapse?
For minor cases of prolapse patients can be tasked with consistent physiotherapy (pelvic floor toning) that can be done at home.

In moderate cases we can insert a pessary ring (small plastic device shaped like a donut) to hold the prolapse in place. This is useful for women who would prefer to delay or are not able to have surgery. This can be done in our clinic.

For more severe cases, surgery followed by physiotherapy may be recommended. This is usually done as a day procedure with a typical recovery time of up to 6 weeks.

Treatment options are typically discussed when the extent of the prolapse has been determined.

All gynaecological surgeries share one common element: rest. Adequate rest allows your body to repair and heal hopefully avoiding complications and negative side effects.

Minor surgeries and procedures (such as colposcopies, laparoscopies and hysteroscopies) may require rest for at least a day or so with some requiring no significant exercise for at least 4 weeks.

More significant and in-depth surgeries (hysterectomies, curettes, prolapse surgeries) will require rest of at least 2 to 6 days with no significant exercise or heavy lifting for 4 or more weeks.

Most gynaecological procedures will incur some bleeding or spotting immediately after and this can last for several weeks. In the event of significant heavy bleeding, excessive pain, smelly discharge or unusual swelling or redness, please contact our clinic or present to hospital accident and emergency. In rare cases, these symptoms can be signs of an infection which may cause complications to recovery.

We understand how devastating a miscarriage can be for couples trying to grow their family. Unfortunately, some couples may experience recurring miscarriages which is usually diagnosed after three consecutive miscarriages.

At Ritu Rana Medical we work with couples to determine if there is a specific cause for recurring miscarriages which may include physical abnormality of the uterus, chromosomal incompatibilities or immunological causes. In rare cases there may not be any specific medical reason for recurring miscarriage.

If you have experienced multiple miscarriages and would like to try for a successful pregnancy you can obtain a referral to Ritu Rana Medical for compassionate and expert assistance.

We would recommend an initial consultation before conceiving again to investigate potential medical issues. At your first visit we will obtain the medical history of you and your partner to review and create a customised plan for your pregnancy.

Once you are in the early stages of pregnancy you can contact us for an appointment where your care will be provided by our medical specialists. The first 12 weeks are crucial for the medical wellbeing of the baby and we will monitor and provide relevant treatment to assist you in a successful pregnancy.