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August 2009 Newsletter
1 Amenorrhoea (Absent periods) following Depo-Provera (hormonal contraceptive by injection)
Dear Mr Viniker
I am very concerned about my infrequent periods, I stopped using the Depo from March 2009, but April I did not see my period, on May I saw my period.
On June my husband was at home, but we did not use anything to protect myself except withdrawal method, but I did not see my periods also, this month of July I did see some small drops for one day. I am so worried that I might be pregnant. Please help.
The reason why I stopped using depo is I was getting too fat and have lost my figure all together.
Please help me.
Kind regards.
A...
Answer:
Dear A....
Sorry to hear about your difficulties.
It is not uncommon for periods to be erratic after stopping Depo-Provera.
This does not mean that you could not conceive whilst the periods are irregular.
If you do not wish to conceive, you must use another form of contraception.
If you are worried that you could be pregnant, you should either do a home pregnancy test or ask your doctor or pharmacist to do one for you.
Depo-Provera is discussed on - http://www.2womenshealth.com/14-Mirena-Mini-Pills/14-20-Depo-Provera.htm
It is unusual to put on more than a pound or two with the use of any hormonal contraception such as Depo-Provera.
I do not believe that any form of hormonal contraception, including Depo-Provera and the combined oral contraceptive pill, can cause loss of figure.
Pregnancy is far more damaging on the figure.
I do hope it all works out for you.
2 Hormone support and recurrent miscarriage
Two questions this month on the concept of hormone support in pregnancy for recurrent miscarriage.
A
Dear Sir,
I want to ask you to send to me studies related to the uses of hCG in treating early pregnancy loss.
:I was registered in women health website.,it is very informative site for all levels.
My Great Regards
B
Hi David thank you very much for the last new letter,i have learnt a lot of things i didn't know. Will you please help me on highlighting more about progestrone during pregnancy .I have had four miscarriages and the recent one was on the 12 of july 2009 at 8wks and during the 4th wk i was told my progestrones were too low and i was put on cyclogest but it could not help double my Bchg quantitative levels they were just increasing and then i was told to stop using the cyclogest in order to miscarry cause the doctor said that it was not a viable pregnancy. I'm however confused of this progestrone thing and can it be treated. Thats what I'm kindly asking you to include in your next newsletter.
Regards
Ro
Answer:
In the early weeks of a pregnancy destined to miscarry, pregnancy related hormones may be low and in particular HCG (human chorionic gonadotrophin) and progesterone.
Progesterone is produced by the corpus luteum - an active part of the ovary where the egg came from. It has an important part to play in maintaining the pregnancy.
http://www.2womenshealth.com/Menstruation-Menstrual-Cycle-Human-Physiology-Hormones.htm
HCG is produced by the pre-afterbirth tissue (trophoblast) and stimulates the corpus luteum to remain active.
It is tempting to assume that supplementation of HCG or progesterone would prevent miscarriage.
There are many endocrine (hormone) deficiency situations where hormone supplements are demonstrably beneficial.
Diabetics (early onset) require insulin and when the thyroid is under active, treatment with thyroxin restores normality.
Many gynaecologists, and I include myself, believed that supplementation with either progesterone, progestogens or HCG might improve outcomes for those with a history of recurrent miscarriage. This was never likely to cause problems but sadly, over the years, controlled studies have failed to demonstrate benefit.
The question arises as to why hormone supplements do not prevent miscarriage whereas in other situations hormone treatments do work. In diabetes or under active thyroid the symptoms are directly related to low hormone levels and the problems are resolved by hormone treatment.
In miscarriage, the pregnancy is failing and hormone deficiency is a sign of this and not the cause. It is like dressing up with warm clothes on a cold day. You may feel warmer but it is still a cold day.
There was once a paper that claimed that HCG could reduce recurrent miscarriage rates:
Br J Obstet Gynaecol. 1994 Aug;101(8):685-8.
The paper was subsequently withdrawn
Br J Obstet Gynaecol. 1995 Nov;102(11):853.
3 Prolapse after hysterectomy
Dear Mr Viniker
Would it be possible to cover the subject of pelvic floor prolapse in a future newsletter particularly in relation to post hysterectomy.
Thank you
Anne .....
Answer:
Dear Ann
Thank you.
Pelvic floor prolapse (vaginal prolapse is discussed on
http://www.2womenshealth.com/Vaginal-Prolapse-Causes-Treatment.htm
Until fairly recently, hysterectomy was undertaken abdominally or vaginally but nowadays there is a third option of laparoscopically assisted vaginal hysterectomy.
During any hysterectomy, the gynaecologist will give thought to attaching ligaments that have supported the uterus into the top of the vagina.
In vaginal prolapse there may be descent of the front of the vagina (cystocoele), back of the vagina (rectocoele) and if the uterus is present then uterine descent.
If the uterus has been removed then the top of the vagina may come down - vault descent.
Usually, vault descent is accompanied by cystocoele and or rectocoele.
Treatment is only required if there are symptoms.
There are is a variety of vaginal rings and pessaries that can be fitted by your gynaecologist.
Vault prolapse can usually be treated during pelvic floor repair when special attention is given to suturing the relevant supporting ligaments into the vaginal vault.
Some surgeons use mesh attached to the top of the vagina and the ligaments near the spine - 2000-01 - and - 2007-01 to provide the required support.
4 Pelvic Floor Dysfunction and Perineometers
hi sir
thanks for sending newsletter to me....i'm doing Master of physiotherapy in obstetric and gynaecology.....my thesis topic is perineometer training to stress incontinence women's...i expect your valuable suggestion...
thank you--
Regards,
Vj
Answer:
Thank you Vj
During normal childbirth, the muscles and ligaments of the pelvic floor are stretched and this may result in prolapse and urinary stress incontinence.
A perineometer is an instrument that measures the strength of voluntary contractions of the pelvic floor muscles. It was Kegel who initiated pelvic floor exercises who developed the perineometer. Ascertaining the air pressure inside the vagina by insertion of a perineometer, while requesting the woman to squeeze as hard as possible, indicates whether or not she would benefit from strengthening the vaginal muscles using the exercises. Modern perineometers measure electrical activity in the pelvic floor muscles and may be more effective in this purpose. Both the perineometer and a digital (internal) examination are effective and concordant in their results in this assessment.
5 Foetal kick charts
Thanks for the update..please,i would like you to help me review the foetal kick count and drugs that could affect it,thanks.
Bay....
Answer:
Mothers are aware of their babies movements. During pregnancy, healthy babies
are generally active except when they are sleeping.
The fetal kick count is an easy, non-invasive test to check the baby's well
being.
There are several ways to count a baby's movements and numerous opinions on how
many movements you are looking for within a certain amount of time. The American
College of Obstetricians and Gynecologists (ACOG) recommends that you time how
long it takes you to feel 10 kicks or movements. Ideally, there should be at
least 10 movements within 10-12 hours. Usually 10 movements are recorded in much
less time.
Though strongly recommended for high risk pregnancies, counting fetal movements
beginning at 28 weeks may be beneficial for all pregnancies.
Some medications, such as those used to treat epilepsy are known to reduce fetal movement.9202
There has been little documented research on the relationship between medication and fetal movement. Kick charts are of value in bringing attention to a reduction in activity.
When fetal activity suddenly reduces or stops, clinical review and a cardiotocograph (CTG) are urgently required.
6 Uterine artery embolisation for fibroids - future pregnancy required.
Dear David,
What are my options? I thought uterine artery embolisation is not appropriate if I want to get pregnant.
Regards,
M
Answer:
Certainly when UAE first started it was felt inappropriate for women who wished to conserve fertility.
Things move on.
From 2001 to 2004, 102 patients with symptomatic uterine fibroids underwent uterine artery embolization in Iran. During the 2-year follow-up period, the patients were asked whether they were trying to achieve pregnancy and whether they were successful. Among 102 women who underwent bilateral uterine artery embolization, 23 (22.5%) were seeking to become pregnant, and 14 of the 23 (61%) became pregnant, nine having been nulliparous. Two miscarriages occurred, one in the 12th and one in the 16th week of gestation. The other 13 pregnancies went to term, were uncomplicated, and ended in elective cesarean delivery. All of the neonates were healthy with Apgar scores greater than 8. The mean weight of the neonates was 3,274. One neonate was small for gestational age (2,100 g). It was concluded that uterine artery embolization can serve as a substitute for invasive operations such as hysterectomy and myomectomy. Additional studies, including prospective, randomized comparisons with myomectomy, should be performed to ascertain whether uterine artery embolization is a safe procedure for women who want to preserve their fertility.
7 Absent periods, ovarian cyst and fertility
sir,iam 29yrs,married on 10th jan 2009.My LMP is 21st june 2009. My UPT is neg .i have been diagnosed with ovarian cyst and taking tablets MEPRETE 10MG and MALA-D since 6 days. but till now i dont get my period. when wiil i get my period again?should i have a chance for pregnancy?
Answer:
Meprete (medroxyprogesterone) is a progestogen that has many clinical applications. Sometimes it can be used to bring on a period. Medicines tend to be allocated different names in different countries. As far as I can see, MALA-D is a contraceptive agent but I wonder if in your country it is used for a different agent.
There are many reasons for periods not occurring -
http://2womenshealth.com/Amenorrhea.htm. Ovarian cysts are common. There are
many types of ovarian cysts. A cyst is a fluid filled sack. The commonest types
of ovarian cysts are small (less than 3 cm) and they are associated with the
development of the egg each cycle -
menstrual cycles
please sir, i will like to ask you some few questions
concerning my problems
Answer: I think you will find the information your require on the following page:
http://www.2womenshealth.com/04-Diagnosis-and-Treatment/therapeutic-focused-ultrasound-fibroids.htm Unfortunately, this treatment is not suitable for everyone. For example, if
there are many fibroids or if there is a scar from previous surgery, then this
treatment is not appropriate.
Dear Doctor,
Thanks a lot for the invitation to write to you. Infact
that something I'd been wishing to do. Doctor, I discovered I have a condition
called Systemic Candidiasis or Chronic candidiasis. There were times I wondered
if it could be Bacterial vaginosis also. I was glad to read the information on
Lactic Acid treatment for Bacterial vaginosis in your newsletter. But I'm more
convinced I have this overgrowth of candida in my Gastro-intestinal tract, which
always results in discharge from my vagina. I wish you could treat this candida
condition also in your next newsletter and also if you could advise on any
treatment options for it.
I'll be looking forward to a reply to this mail and if
you'd like to ask me any questions, I'm eager to have a discussion with you.
Thanks a lot, Doctor,
With Kind regards,
S...........
Answer: About one per cent of women will have more than six episodes of
vaginal candida a year.
Swab tests should be taken to confirm that you really are having bouts of thrush. Whilst most people have heard of thrush, relatively few know about
bacterial vaginosis and this is more
common than thrush. It is prudent to exclude underlying illness and to correct other causes of vaginal discharge such as cervical ectropion (erosion
cervical erosion). One of the orally active agents may eliminate the reservoir of candida in the bowel although this may subsequently recur. The objective is to prevent recurrence.
Hi
I have been told that I have a 11cm x7cm dermoid cyst on right ovary. I have
been waiting since last November for a diagnoses to why I was having pelivic
pain -bloated stomach- missing periods-increased hair on face-bad mood swings-
after a lot of nothing from the Doctors I asked for an ultra scan this
year (done in march) which found the dermoid cyst. MRI and blood tumor markers
say not cancer.
I am awaiting surgury which is in september I am in a lot of pain now and right
side gets hot and burns. My doctor says its not serious and the Gynea don't seem
to worried.
What I would like to know are dermoid cysts common and what causes them. I
cannot seem to see anything on the wesite about these cysts
Many thanks
Answer: This is a cyst that usually affects younger women and may grow to 20 cm in
diameter. Dermoid cysts are very common. It is a type of benign tumour sometimes
referred to as cystic teratoma or benign teratoma. This cyst can contain fat and
occasionally bone, hair, teeth and cartilage.
About 15% of women with ovarian teratomas have them in both ovaries. They
can cause the ovary to twist (torsion) and endanger its blood supply.
please i would like you to treat high prolactin or fliud
coming out of the breast of a woman who is not pregnant nor nursing a baby
Answer: The diagnosis and treatment of inappropriate milk
production are discussed on
http://www.2womenshealth.com/06-Absent-Periods/06-21-Amenorrhoea-Treatment.htm and Miscarriage is an emotionally challenging ordeal accompanied
by all the feelings of bereavement. When it occurs more than once it may,
understandably, be a devastating experience. In many countries, women are
delaying their families by about five or more years compared to the previous
generation. Fertility decreases with age. Furthermore, genetic problems such as
Down Syndrome increase with maternal age. In older patients with recurrent pregnancy loss, fetal chromosomal
abnormalities are responsible for the majority of miscarriages. Other causes
were present in only 20% of cases.09011 Placenta praevia is associated with vaginal bleeding in the later stages of
pregnancy and in labour. Ultrasound can show the relationship between the lower
edge of the placenta and the internal cervical os.
In a study from Italy, more than two-thirds of women with a placental edge
to cervical os distance of >10 mm deliver vaginally without increased
risk of haemorrhage. If the pregnancy is in the uterus and allowed to continue to term there is inevitably concern that the fetus may have been damaged. Early reports do not suggest a significant increased risk. Certainly there is no support for the concept that pregnancy should be terminated because of failed post-coital contraception. A study from China found no evidence of harmful effects.0901 Thank you . Pls.. Give detail of treatment of pcod. With dose,
duration , name etc. With which hormone level what strength of drug to be
given?. J. - India Dear J Thank you for your question. I do hope that you would appreciate that I am not in a
position to offer treatment advice on an individual patient basis. No doctor would prescribe without the benefit of a full
consultation. It would be unethical to do so. The treatment of PCOD is dependent on the individual
patient's set of problems. One lady with PCOD may have infrequent periods and does
not wish to conceive at the moment. The combined oral contraceptive pill might be a suitable
option for her. Another woman with PCOD might have infrequent periods
and infertility. Clearly the combined oral contraceptive pill would not
be in her interest. I hope that one of my website articles may help you.
http://www.2womenshealth.com/PCOS-Polycystic-Ovary-Syndrome.htm Kind Regards David A Viniker MD FRCOG Over recent years, new techniques have become available that avoid major
surgery notably uterine artery embolisation and focused ultrasound. A retrospective follow-up cohort study included all patients described in a
2006 publication who had uterine artery embolisation. Assessment was focused on comparing symptoms and quality of life in long-term
follow-up. The analysis was based on questionnaires completed by 39 patients. The median follow-up period was 7 years. Uterine fibroid embolization led to a reduction The median impairment scores for bleeding and pain decreased significantly
from 7 to 0 and from 5 to 0 (both p < 0.001). The general quality-of-life index increased significantly from 4.5 to 9 (p <
0.001). In the long term, there was no significant difference in parameters
assessed compared with the midterm follow-up findings. Six patients (15.4%)
underwent hysterectomy an average of 32.1 months after intervention. Thirty-two
patients (82.1%) continued to be satisfied with the intervention, and 30
patients (76.9%) answered that they would recommend uterine fibroid embolization
to other patients.0901 Until recently little was known about the relationship between
alcohol consumption and cancer. A recent study has confirmed that alcohol does
increase cancer risk.0901 With the exception of breast cancer, little is known about the
effect of moderate intakes of alcohol, or of particular types of alcohol, on
cancer risk in women. A total of 1,280,296 middle-aged women in the United
Kingdom enrolled in the Million Women Study were routinely followed for incident
cancer.A quarter of the cohort reported drinking no alcohol; 98% of drinkers
consumed fewer than 21 drinks per week, with drinkers consuming an average of 10
g alcohol (1 drink) per day. During an average 7.2 years of follow-up per woman
68,775 invasive cancers occurred. Increasing alcohol consumption was associated with increased
risks of cancers of the breast (12%), and total cancer (6%, 95% CI = 4% to 7%,
Ptrend < .001). The trends were similar in women who drank wine exclusively and
other consumers of alcohol. For every additional drink regularly consumed per
day, the increase in incidence up to age 75 years per 1000 for women in
developed countries is estimated to be about 11 for breast cancer, 1 for cancers
of the oral cavity and pharynx, 1 for cancer of the rectum, and 0.7 each for
cancers of the esophagus, larynx and liver, giving a total excess of about 15
cancers per 1000 women up to age 75. Ovarian cancer develops deep inside the pelvis and sadly by the
time symptoms arise, the disease is usually advanced. Whereas cervical screening has proven to be an effective means
to prevent cervical cancer, there is no equivalent preventative option available
for ovarian cancer. Screening for early ovarian cancer by pelvic ultrasound and
screening for tumour markers are available but benefits are not as great as
anticipated (April
2009 Newsletter). For advanced ovarian cancer, surgery with debaulking has been
the recommended treatment. Whenever possible, surgical removal of the ovaries and uterus is performed. Chemotherapy has an important part to play.
Cytoreductive surgery followed by platinum based systemic chemotherapy is an
effective treatment for advanced ovarian epithelial carcinoma, resulting in up
to 80% complete response (CR) rate; however only 30% of patients reaches 5-year
survival. An "open" intra-abdominal hyperthermic perfusion with 25
mg/m(2)/lt cisplatin of perfusate or 50 mg/m(2)cisplatin plus 15
mg/m(2)doxorubicin was carried out throughout the abdomino-pelvic cavity on 42
patients affected by peritoneal carcinomatosis from ovarian primary, soon after
tumor removal en bloc with regional involved peritoneum. Clinical and oncologic
data have been prospectively recorded on a dedicated database. RESULTS:
Forty-two patients, submitted to peritonectomy, achieved no residual macroscopic
disease in 83% of the cases. Hyperthermic chemoperfusion was performed in 95% of
the patients. Major complications were observed in 21.4%, being directly
correlated to the duration of the surgical procedure (p=0.03). The operative
mortality was 4.7%. At a mean follow up of 22 months, the overall 3-year
survival was 61.4%, with a median survival of 41 months. Careful selection of
patients could reduce surgical risk and further improve survival.0901
New delivery systems for delivering chemotherapy are under development.0501
Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women during their reproductive years; it is more common than “thrush". Some studies indicate that up to 30% of women are affected0701 The discharge has a fishy odour, which is intensified after intercourse and during menstruation. Itching and soreness are not features of BV. In 1983 the condition was called bacterial vaginitis but inflammation of the vagina is not a feature and it was renamed vaginosis. There have been other names including non specific vaginitis, haemophilus vaginitis and non specific vaginosis. Lactic acid gel has become available in gel format from
December 2008 as Relactagel. The incidence of bacterial vaginosis (BV) in pregnant women
is 15-20%. It has been suggested that significant numbers of pre-term births
can be prevented in women considered to be of “high” or normal risk for pre-term
birth, by screening and treating BV in pregnancy. Bacterial vaginosis is
thought to occur as a result of a change in vaginal pH mediated by the metabolic
activity of anaerobic bacteria.
A natural approach to restore normal vaginal pH without any
drug intervention is merited. Relactagel, a lactic acid gel, delivers a
natural body substance to the site of bacterial infection to lower vaginal pH
and encourage lactobacilli proliferation. Glycogen is also added as a substrate
to further enhance lactobacilli growth thus re-establishing the normal vaginal
ecosystem and aiding the elimination of the discharge and characteristic
unpleasant odour. This preparation is available without prescription. Lactic acid restores natural vaginal acidity and has been
shown to treat and prevent bacterial vaginosis.8601,
9003 Application of Relactagel as a preventive measure
may also help to avoid onset of this condition as well as reduce frequency of
recurrence. Furthermore, this natural approach may also be the preferred choice
of treatment, particularly in pregnancy, where the lactic acid simply helps the
body to help itself! Each pack contains seven easy applicator disposable tubes.
To treat moderate problems use one single tube every day for 7 days at bedtime.
For prevention, one single tube every day for 2-3 days after menstruation is
recommended.
In a recent review0901
the data has been evaluated cto assess the medical outcome for IVF/ICSI children
born after cryopreservation, slow freezing and vitrification of early cleavage
stage embryos, blastocysts and oocytes. A systematic review was performed. The
authors searched the medical databases from 1984 to September 2008. For early
cleavage embryos, data from controlled studies indicated a better or at least as
good obstetric outcome, measured as preterm birth and low birthweight for
children born after cryopreservation, as compared with children born after fresh
cycles. Most studies found comparable malformation rates between frozen and
fresh IVF/ICSI. Data concerning infant outcome after slow freezing of
embryos was reassuring.
8 Focused Ultrasound Treatment For Fibroids
i have fibroid and i had the first operation in April 22nd 1996 back home.and is
grown back now
and since 2005 i have been going for treatment each time i went for treatment i
will be ask to go for ultrasound
after which they will tell me that the only way to treat is to be operated and
its fifty-fifty chance.that is they might remove
my uterus in the process or if they leave it i might not be able to have
children.
As i was checking through the Google i saw what they wrote about MRI therapy for
fibroid and again i check your website
too.please i need you to explain to me everything i need to know cause i don't
want to loose my womb.i really need help please.
waiting to hear from you.
thanks
c...9 Vaginal Discharge and Recurrent Candidiasis
10 Dermoid Cysts
Removal is usually the treatment of choice by laparotomy (open surgery) or
laparoscopy.
11 Galactorrhoea
The Literaturee
Recurrent Miscarriage and Age
Placenta Praevia and Vaginal Delivery
Are there any risks if pregnancy continues after
Levonorgetrel emergency contraception?
July 2009 Newsletter
Question: - Request for patient specific advice
Management of Fibroids - Uterine Artery Embolisation
Alcohol and Cancer
Advanced Ovarian Cancer Management
Ovarian cancer spreads early in the disease into the abdomen.
Lactic Acid For Bacterial Vaginosis
IVF - Crypreservation (Embryo Freezing) and the Health of the baby
In spontaneous conception, the one follicle that has become dominant that cycle is fertilised by the sperm that has beaten all the others in a race. There have been millions of sperm released during the ejaculation. The concept of natural selection is dependent on the idea that the fittest survive. Infertility treatment, particularly IVF, ICSI and cryopreservation circumvent natural selection. There has been understandable concern that these infertility treatments may be associated with an increased risk of congenital abnormality. Reassuringly, however, results reported from around the world indicate that there is no major increase in the rate of babies being born with abnormality.
This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.
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