When a Hysterectomy Should Be Considered

When A Hysterectomy Should Be Considered

Many times I have talked about “Why a hysterectomy does not cure endometriosis” and so I have decided to talk about “When a hysterectomy should be considered”

Now, before you go any further, I need people to sit back, listen objectively and also take the personal out of this. This is a very personal topic and yes, I am a man and a male healthcare practitioner all in one, with over 20 years experience in helping women with women’s health conditions and being a voice for them also. But regardless, this topic does need to be talked about. Any negative comments, or rudeness will get the delete button immediately. Constructive discussion is always welcome.

The long and short of it is this. There are times when a hysterectomy should be considered (lack of quality of life, cancers etc) and we need to be able to give women the facts so that they can make informed choices, and also not be judged for those choices either. The fact is that for some conditions, women actually get their life back after having a hysterectomy and I talk about all of this and more in this video blog.

 

Adenomyosis 2

Let’s Talk About Adenomyosis

As a healthcare practitioner with a special interest in women’s health, more and more I am seeing women presenting with all the symptoms of Adenomyosis. This is why this post is called “Let’s Talk About Adenomyosis”.

Just like endometriosis, many women have had this condition missed and dismissed and then have to suffer the consequences and think that they just have to put up with it month after month.

Some women are completely unaware that they have adenomyosis. Those that have already been diagnosed with endometriosis often believe that all their symptoms are just related to this disease only, when it fact, they could have two diseases creating all their issues.

Many of the symptoms are the same as endometriosis, except that women will usually have heavier menstrual bleeding, or irregular bleeding issues.

Women can have both endometriosis and adenomyosis at the same time and now research is showing that they are basically one in the same disease, but just in different locations.

What is Adenomyosis?

Adenomyosis is defined as the presence of endometrial glandular tissue occurring deep in the endometrial lining (myometrium). The exact cause of adenomyosis is unknown, but current research is showing that it is a similar process to how endometriosis is caused.

Histologically both endometriosis and adenomyosis are one in the same disease state, but just occurring in different locations. We know that both diseases are driven by estrogen and that they have all the same signs and symptoms. Adenomyosis and endometriosis are not caused by estrogen dominance either. Even small amounts of estrogen will drive both diseases.

The only difference between the two disease states is that adenomyosis typically causes more heavy bleeding symptoms. The abnormal bleeding occurs when the ectopic endometrial tissue induces hyperplasia and hypertrophy of the surrounding myometrium. This causes uterine enlargement and subsequent changes in vascularisation (the new vessels may also be more fragile than usual) in addition to an increase in the surface area of the endometrium.

One of the key diagnostics for adenomyosis is the presence of an enlarged uterus on ultrasound, or via MRI. The enlarged uterus can also impact the surrounding structures and often impacts the bladder, leading to urinary frequency and other bladder issues.

Adenomyosis can also have the same bleeding symptoms as fibroids but correct diagnosis and investigations, will differentiate the two and ensure correct management moving forward.

What Are the Symptoms of Adenomyosis?

As mentioned previously, adenomyosis has all the same symptoms as endometriosis. Just like endometriosis, some women often have no symptoms (are asymptomatic), and are only diagnosed when they are having issues trying to conceive.

The main symptoms of Adenomyosis are:

  • Heavy, prolonged menstrual bleeding
  • Severe pain and menstrual cramps
  • Abdominal pressure and bloating
  • Bladder issues (frequency, urge frequency, incontinence)
  • Anaemia

Other associated symptoms such are:

  • Irregular bleeding
  • Pain with bowel movement
  • Irritable Bowel like symptoms
  • Urinary Tract Infection (UTI) like symptoms
  • Fatigue
  • Mental and emotional disturbances (depression, premenstrual dysphoric disorder)
  • Pain with intercourse
  • Infertility
  • Musculoskeletal pain
  • Lack of quality of life

Diagnosis of Adenomyosis.

Ultrasound is the most common (and indeed most useful) first-line imaging tool used to diagnose adenomyosis in a women presenting with any abnormal uterine bleeding. While ultrasound cannot definitively diagnose adenomyosis, it can help to differentiate and rule out other conditions with similar symptoms.

Sometimes saline solution is injected in the uterus at the same time as ultrasound is performed to give better imaging and to help evaluate the symptoms associated with adenomyosis. This is called sono-hysterography.

While trans-vaginal ultrasound (TVU) can be used, it can also miss the disease, especially if the user doesn’t have an expert eye, or extra training, or specialises in the diagnosis of adenomyosis.

MRI is considered a much better tool for the finding of adenomyosis, but it is a more expensive option. Even though ultrasound is a cheaper option, it can be inaccurate.

Blood tests cannot diagnose adenomyosis, or endometriosis.

The only proper way to definitely diagnose adenomyosis is via surgical intervention and a biopsy, but this is rarely done prior to a hysterectomy due to risk factors of damage to the uterine lining. Unlike endometriosis, the disease cannot be excised and the only cure for adenomyosis is hysterectomy.

Treatment and Management Options For Adenomyosis

The treatment and management of adenomyosis will depend in part on your presenting symptoms, their severity, and whether you have completed childbearing.

The medical management options for adenomyosis are usually in the form of hormonal therapy (the Oral Contraceptive Pill, Mirena IUS or other types of progestogen therapy) or surgical.

The surgical options are endometrial ablation, uterine artery embolism and hysterectomy. When considering surgical therapy it must be acknowledged that endometrial ablation and uterine artery embolism is less effective compared with the more definitive but more invasive option of hysterectomy.

Research does show that a significant portion of women, who choose to do endometrial ablation, or uterine artery embolism, will end up needing a hysterectomy. Hysterectomy is not the major procedure it was years ago and many are done laparoscopically and done intravaginally. This also helps with the recovery time. It all gets back to quality of life for many women with endometriosis. This is why hysterectomy is now a better option than other surgical interventions.

While hysterectomy is not something to be taken lightly, we do need to be real about quality of life and the ongoing pain, other associated symptoms, long term bleeding and the dangers of long term anaemia that adenomyosis can cause to a woman. Many women often quote getting their life back and wished that they had the hysterectomy sooner, rather than putting up with the lack of quality of life. Hysterectomy is a cure for adenomyosis, but it is not a cure for endometriosis.

Other Management Options For Women With Adenomyosis

  • Medical treatments(pain medications, iron infusions)
  • Complementary medicines (Acupuncture, Chinese herbal medicine, vitamins and nutrient support),
  • Nutrition and diet
  • Counselling & Psychology
  • Meditation and Mindfulness
  • Pain management clinics
  • Physiotherapy
  • Exercise therapy(weight baring exercise, resistance training)
  • Core strengthening(pilates, yoga)
  • Pelvic floor management(Pilates, Kegels Exercises/Kegels balls, Vaginal stone eggs),
  • Urodynamics

For women who do not want to consider surgical options, adenomyosis requires a multimodality/team approach for ongoing management, treatment and support. In most cases it will need a combination of the therapies above, or all of them, in conjunction with medical interventions and medicines.

In nearly all cases, treatment and management is the same as endometriosis, except there needs to be more focus on the heavy bleeding symptoms. I always apply a multi-modality approach to assist all my patients who have adenomyosis, or endometriosis, or both combined.

Mild symptoms may be treated with over-the-counter pain medications, complementary medicines and supplements and the use of heating pads to ease pain and cramps. It is important to talk to your healthcare practitioner about treatment options to suit your individual needs and individual symptoms.

Outlook For Women With Adenomyosis

Adenomyosis is not a life-threatening condition, although if some symptoms, such as anaemia and emotional disturbances, aren’t managed properly, or early on, it could potential be life threatening. Many of the symptoms such as heavy bleeding, pelvic pain, pain with intercourse, anaemia and bladder and bowel issues can, and do negatively impact a woman’s life.

Women with adenomyosis are often anaemic and long-term anaemia can have serious health consequences. See my post of serious consequences of iron deficiency. Click here

Many women with adenomyosis, if not all, will need an iron infusion if their iron levels are low. See my post “Could you need an Iron Infusion?”

While surgical options such as hysterectomy can cure adenomyosis, there are both medical and complementary medicines available that may help alleviate the symptoms of adenomyosis.

Adenomyosis and associated symptoms can resolve on their own after menopause. If women have endometriosis as well, they will often require ongoing treatment and management after hysterectomy, as hysterectomy does not cure endometriosis. As mentioned previously, hysterectomy will cure adenomyosis.

Anyone with symptoms of adenomyosis should consult a medical specialist, a healthcare practitioner that specialises in adenomyosis and endometriosis.

Final Word

If you do need help and assistance with the management of adenomyosis, the please call my friendly staff to find out how I may be able to assist you. My motto is ‘no stone left unturned’ and I apply this to every person I see and help. I also have a network of other healthcare professionals I work with as well.

Regards

Andrew Orr

-No Stone Left Unturned

-Master of Women’s Health Medicine and Master of Reproductive Medicine

-The Endometriosis Experts (incorporating adenomyosis as well)

 

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Let’s Talk About Ovarian Cancer

Ovarian cancer often has no symptoms in the early stages. Later stages are associated with symptoms, but they can be non-specific, such as loss of appetite and weight loss.

Ovarian cancer often goes undetected until it has spread within the pelvis and stomach. At this late stage, ovarian cancer is more difficult to treat and can be fatal. This is why early intervention is something I am very big on and why we all need to not put things off when they present themselves.

Ovarian cancer is the 9th most common cancer diagnosed in Australian women.

Ovarian cancer is the 6th most common cause of cancer death in Australian women.

The present life expectancy of Australian women is 84 years. One in 77 women will be diagnosed with ovarian cancer before the age of 85.The risk of ovarian cancer increases with age. About 83% of all new cases of ovarian cancer diagnosed in 2005 were in women 50 years or older. The median age of first diagnosis is 64 years.

The five year survival rate for ovarian cancer is 45%.

Symptoms
Most women with ovarian cancer experience at least one symptom of the disease in the year prior to their diagnosis. The following can all be signs of ovarian cancer:

  • Abdominal bloating
  • Abdominal or back pain
  • Appetite loss or feeling full quickly
  • Changes in bowel habit
  • Urinary frequency or incontinence
  • Pain during intercourse
  • Menstrual irregularities
  • Unexplained weight loss or gain
  • Indigestion or heartburn

Why is bloating a sign of ovarian cancer?

Ascites (a build-up of fluid in the abdomen and a sign of advanced ovarian cancer) is probably the major cause of bloating in women with ovarian cancer. Therefore, waiting for bloating as a key ‘sign’ is too late and we want to encourage all women to ‘know your normal’ and if this changes, to seek medical help. This is why any changes in the body need to be looked into. Many may think that they are reacting to foods, or they have a gut issue etc, but it may actually be the signs of ovarian cancer. This is why proper investigations and proper differential diagnosis by a trained professional is so important.

Family history
While having a family history of ovarian cancer increases a woman’s risk of developing ovarian cancer, 90-95 per cent of all ovarian cancers occur in women who do not have a family history.

Key factors associated with increased risk include:

  • Multiple relatives on the same side of the family affected by breast cancer (male or female) or ovarian cancer
  • Younger age at cancer diagnosis in relatives
  • Relatives affected by both breast and ovarian cancer
  • Relatives affected with bilateral breast cancer
  • An increase in age
  • Inheriting a faulty gene (called a gene mutation) that increases the risk of ovarian cancer
  • Being Caucasian (white) and living in a Western country with a high standard of living having few or no full-term pregnancies
  • Starting your menstrual cycle early (before the age of 12) and beginning menopause after the age of 50
  • Taking hormone therapy (HT) after menopause. Some studies suggest this may increase your risk of developing ovarian cancer, but others don’t make this connection
  • Never having taken the contraceptive pill – the pill has been found to reduce the risk of cancer of the ovaries and uterus
  • Only five to 10 per cent of all ovarian cancers are associated with a family history. The risk of developing ovarian cancer increases with the number of affected first degree relatives (parents, siblings, children)
  • Ashkenazi Jewish ancestry.

Diagnosis for Ovarian Cancer

There is currently no evidence to support the use of any test, including pelvic examination, CA125 or other biomarkers, ultrasound (including transvaginal ultrasound), or a combination of tests, to screen for ovarian cancer. The only way to properly screen for it is through histology done at the time of laparoscopy.

While CA126 can be a diagnostic, it really has limited value and I have to let people know that it isn’t the best diagnostic at all. 50% of ovarian cancers will actually have a normal CA125 reading.

The cancer council’s guidelines are quite clear about this after numerous research studies show that CA125 has limited diagnostic value for Ovarian cancer. If markers and symptoms are suggestive of Ovarian Cancer, the only true diagnostic is Laparoscopy with histology to really get an accurate diagnosis.

Treatment for Ovarian Cancer

At such an advanced stage, the cancer is more difficult to cure. As ovarian cancer advances, cells from the original tumor can spread (metastasize) throughout the pelvic and abdominal regions and travel to other parts of the body. Cancer cells are carried through the body through lymph vessels and the bloodstream.

If a woman is suspected of having ovarian cancer, she should be referred to a gynaecological oncologist. Research shows survival for women with ovarian cancer is improved when their surgical care is directed by a gynaecological oncologist.

Treatment for ovarian cancer usually involves surgery and chemotherapy. It may also include radiotherapy.

Usually your healthcare practitioner, or GP, will generally arrange for initial tests and looks after your general health as well as coordinating with your specialists. Depending on your treatment you will be seen by several specialists, such as: medical oncologist, radiation oncologist, radiologist, gynaecological pathologist, cancer nurses and other health professionals such as a dietitian, physiotherapist, social worker and a counsellor.

With any condition that affects the body, we often get early warning signs and this is why early intervention and making sure you are investigated and management properly is so important.

Regards

Andrew Orr

-Women’s and Men’s Health crusader

-No Stone Left Unturned

-The Women’s Health Experts

01 Dr Andrew Orr

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Is it Endometriosis, or Adenomyosis, or both?

Endometriosis and Adenomyosis can often present with the same symptoms and many now believe they may be one in the same disease, just in different locations.

Despite both of them sharing similar symptoms, there are pointers for properly trained professional to which disease may be presenting. Both diseases are often missed and dismissed as well. To learn more about Endometriosis, or Adenomyosis please click on the hyperlinks.

I have previously put up posts about hysterectomy not being a cure for endometriosis. It often causes lots of people to question this statement, because some uneducated healthcare practitioner has told them differently. Some may have had some relief from having a hysterectomy and now believe their endometriosis has gone.

Before I go any further, I do need people to know the facts. Hysterectomy does not cure endometriosis, but is can help Adenomyosis. There is no cure for endometriosis. I have explained the reasons why in my resent post Hysterectomy does not cure endometriosis. Please click on the hyperlink to find out the facts.

Many women who have Endometriosis, or Adenomyosis are often missed and dismissed for up to 10 years or more, before a diagnosis is made. This is due to the fact that many healthcare practitioners do not know the symptoms of these disease states, or dismissed them as being normal. That is a fact. This is why it is important to see someone who has a special interest in Endometriosis, or Adenomyosis.

With both Endometriosis and Adenomyosis, they share many common symptoms such as:

  • Painful periods
  • Pain with intercourse
  • Ovulation Pain
  • Dark and clotted menstrual blood
  • Digestive upset
  • Pain on bowel movement
  • Bowel or bladder issues
  • IBS like symptoms
  • Pelvic pain and rectal pressure
  • Infertility

What is the difference between Endometriosis and Adenomyosis?

The one thing that usually sets them apart is that Adenomyosis usually has more heavy menstrual bleeding, abnormal uterine bleeding and more flooding symptoms. Endometriosis can have this too, but usually adenomyosis presents with more blood loss symptoms and abnormal bleeding.

Endometriosis ‘cannot’ be definitively diagnosed via ultrasound, or MRI, but adenomyosis can be diagnosed via both of those methods. Endometriosis can only be definitively diagnosed via surgical intervention (laparoscopy). This is the biggest difference with the two disease states. The other thing is that both disease states can be present at the same time and quite often do.

The biggest issue for many women is that when one disease state it found, the other one is quite often overlooked, or misdiagnosed. Many women, and healthcare professionals, are unaware that both the disease states can be present at the same time and this is a real issue.

Hysterectomy will help Adenomyosis, but it ‘will not’ cure Endometriosis.

As I have mentioned earlier, hysterectomy does not cure endometriosis, but it can help adenomyosis. Many women have been led to believe that hysterectomy will cure their endometriosis and associated symptoms, but this is not true.

Some women who have had a hysterectomy and then think they are getting relief from symptoms of endometriosis, but are actually getting relief from adenomyosis not being there anymore. It is just that they did not know it was there, they have never been diagnosed, and then believe their endometriosis is cured. Once the uterus is removed, the adenomyosis is removed too. Then all the adenomyosis abnormal bleeding, period pain and period related symptoms are usually gone as well.

The only trouble is, if a woman has been diagnosed with endometriosis, the endometriosis will still be there. That is a fact. Endometriosis does not miraculously go away after a hysterectomy. Endometriosis is not in the uterus. Some symptoms (usually the menstrual related symptoms) can settle for some people, but for many it does not. Regardless the endometriosis will still be there and can continue to grow and cause havoc elsewhere in the body too.

Proper investigation is important

When women come to see me for help with Endometriosis, or Adenomyosis, I always make sure they are investigated for both disease states. If a women has abnormal uterine bleeding, or heavy menstrual bleeding and they have only been diagnosed with endometriosis, I will always make sure that they are investigated to see if they have Adenomyosis as well. I will also screen for genetic issues such as Von Willebrand’s Disease and other pelvic pathology that may cause bleeding as well.

It is also very important that women with both Endometriosis, or Adenomyosis, or both are are also screened for iron deficiency too.

Hope this explains a little bit more about Endometriosis and Adenomyosis and a bit more about which disease state hysterectomy will, or won’t help.

If you do need help and assistance in managing endometriosis, or adenomyosis, or both, please give my friendly staff a call and find out how I may be able to assist you.

Regards

Andrew Orr

-No Stone Left Unturned

-The Endometriosis Experts

-The Women’s Health Experts

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Von Willebrand Disease

Von Willebrand Disease (VWD) is the most common inherited bleeding disorder diagnosed in women with heavy abnormal uterine bleeding, due to a coagulation defect.

Women with this disease may also have some tendency to bruising/nosebleeds in childhood but it will be when they get there first period that deficiency in von Willebrand factor – an essential protein required for both normal platelet function and as a co-factor to Factor VIII in the clotting cascade, most frequently presents.

A parent with VWD has a 50 per cent chance of passing the affected gene on to each child. VWD can affect both men and women. Sometimes genes mutate or change and can skip generations. Sometimes a child may have VWD but there was no family history of the condition. This means that VWD can occur in any family.

Women with this condition will present with excessive or prolonged bleeding with all other investigations normal (e.g. structural abnormalities are excluded). The diagnosis of Von Willebrand’s disease is by means of a coagulation screen and vWF antigen testing.

History behind Von Willebrand’s disease

Von Willebrand’s disease is named after Dr Erik Adolf von Willebrand, a Finnish paediatrician. In 1924, a 5-year-old girl was brought to the hospital in Helsinki where von Willebrand worked. He diagnosed her with a bleedingdisorder which he recognised was different from the haemophilia which was initially suspected. He subsequently assessed 66 members of her family and in 1926 first described the disease and its inheritance.

Von Willebrand’s disease is the commonest coagulation defect in humans-but is also seen in dogs (notably Doberman Pinschers),and more rarely in swine, cattle, horses, and cats.

Symptoms of Von Willebrand’s Disease

Many people with the disease do not have any symptoms. Those who do may find that they:

  • have lots of nosebleeds
  • bruise easily
  • have heavy menstrual (period) flow
  • bleed excessively from the mouth.
  • The presence in your menstrual flow of blood clots greater than 1 inch (2.5 centimeters) in diameter
  • The need to change your menstrual pad or tampon more often than hourly
  • The need to use double sanitary protection to control menstrual flow
  • Symptoms of anemia, including tiredness, fatigue or shortness of breath

There are three main types of VWD:

  • Type 1
  • Type 2
  • Type 3.

These can be broken down into further categories. The most common are types 2A and 2B.

Complications of von Willebrand disease may include:

  • Anaemia– Women who experience heavy menstrual bleeding are more at risk of iron deficiency anaemia.
  • Swelling and pain-If abnormal bleeding occurs in the joints or soft tissue, swelling and severe pain can result.
  • Death from bleeding –Rarely, someone with Von Willebrand’s Disease may experience uncontrolled bleeding that can be life-threatening and needs emergency medical attention.

There are hormones and other medications that can help with the acute bleeding that can present with VWD.

Although Von Willebrand’s Disease is the most common pathology, other bleeding disorders including thrombocytopaenia and haemophilias should be considered. Consultation with a haematologist should be considered when a coagulation defect is diagnosed, or when the history suggests a clotting disorder. The main aim is to to manage the underlying disease but to also help with effective menstrual regulation (usually with combined contraceptive pills).

Regards

Andrew Orr

-Women’s and Men’s Health Advocate

-No Stone Left Unturned