Obstetrics & Gynaecological Services

A woman’s menstrual cycle usually commences around the age of puberty (12-14yrs of age, although it may be earlier or later). The first few cycles may be irregular (amount, duration and length) although once a regular cyclical pattern of bleeding has been established, any changes may indicate an underlying cause which will need to be investigated.

You may have abnormal uterine bleeding if you have one or more of the following symptoms:

• You get your period more often than every 21 days or further apart than 35 days
• Your period lasts longer than 7 days
• Your bleeding is heavier than normal or associated with clots.
• If there is significant associated pelvic/lower abdominal pain
• If you are developing symptoms or signs of anaemia (tiredness, syncope, palpitations)

Chronic pelvic pain means that you have experienced pain symptoms for more than 6months which may not be confined to the time of your period and is often associated with a chronic disorder or underlying condition eg. endometriosis, infection, prolapse, fibroids, tumours, cysts on ovaries, irritable bowel syndrome, other problems with bowel, bladder or nerves. Sometimes, despite all kinds of investigation we may not find the cause of pelvic pain.

The most common cause of pelvic pain is endometriosis, in which pieces of the lining of the uterus (endometrium) is found outside of the uterus and may attach to other organs or structures within the pelvis and abdomen. Most patients will eventually require a small “keyhole” surgical procedure (laparoscopy and biopsy) to confirm the diagnosis of endometriosis. There are various modalities of treatment for this condition which need to be tailored to your specific needs.

Fibroids are non-cancerous tumours/growths that arise from the muscle layer of the uterus and typically develop during one’s reproductive years under the stimulation of oestrogen. They may vary in size, number and location (in relation to the uterus) and most often are asymptomatic. When they do cause symptoms, these may include menstrual abnormalities (usually heavy cyclical bleeding), infertility or recurrent miscarriages, pressure symptoms on the surrounding structures eg. the bladder/bowel causing frequent urination or constipation respectively or the presence of a mass in the lower abdomen/pelvic area. Fibroids are usually diagnosed on examination & by ultrasound.

If fibroids cause symptoms, they should to be treated – various modalities exist, some which treat the symptoms but do not remove/shrink the fibroids (some birth control methods), while other modalities (surgical/non-surgical) address the fibroids themselves.

Depending on their size, location and number, surgical removal of fibroids can be performed hysteroscopically (via the uterine cavity & vagina with no need for surgical scars on the abdomen), laparascopically (key-hole surgery) or via a laparotomy (larger incision on the abdomen).

Endometriosis is a condition found in women during their reproductive years and is characterised by the presence of endometrial tissue (the lining of the uterus which sheds during a menstrual cycle) in places outside of the uterus. The most common sites that this endometrial tissue can be found are on your ovaries, fallopian tubes and the tissue lining your pelvis (peritoneum) with pain being the predominant symptom. This includes pain, which is worse during the menstrual cycle, pain wih intercourse and sometimes pain with passage of urine/stool. Other symptoms include abnormal bleeding and infertility.

While the cause of endometriosis is multifactorial, there may be a strong genetic link. While the history may be very suggestive and one must always maintain a high index of suspicion of endometriosis, it is often not picked up by our conventional pelvic ultrasound (unless it causes an ovarian cyst also called a “chocolate cyst”). Endometriosis is most reliably diagnosed by diagnostic laparascopy (keyhole surgery where a camera is inserted through the belly-button) and one may treat the condition surgically at the same time.

Treatment depends on the woman’s age, her symptoms and her fertility requirements (immediate & long term). Treatment modalities include hormonal treatment to suppress the growth of endometrial tissue or surgery especially when fertility is desired or if medical management has failed.

An ovarian cyst is fluid-filled growth that forms on the ovary usually during the reproductive years. While they are quite common, they generally cause no symptoms and are mostly detected as an incidental finding while having a pelvic ultrasound. Majority of ovarian cysts are what we call “functional” cysts which means that they develop at different parts of a woman’s cycle depending on the function of the ovary (most commonly before/during/after ovulation. These cysts usually resolve without treatment although if causing pain, your gynaecologist may recommend hormonal suppression using a birth control pill. Ovarian cysts that may require surgical intervention are those that have grown and are now causing pain, bloating, nausea or pressure on the bladder or bowel. Although most are non-cancerous, they can complicate eg. rupture or undergo torsion, which may warrant emergency surgery.

There are many other types of ovarian cysts and these may only be differentiated by how they look on ultrasound (eg. endometriomas/chocolate cysts, dermoid cysts which can contain hair & teeth) or finally once your doctor has removed them and sent them for microscopic examination.

Ovarian cancer is rare and is a more common in ladies over the age of 50 years (unless one has a strong family history of breast/ovarian/uterine/colon cancer). Any ovarian cysts in a postmenopausal patient requires further investigation and often surgical removal.

Infertility is defined as failing to conceive after 12 months of unprotected intercourse, at least 2-3 times/week. If you are ≥35yrs old however, your gynaecologist may recommend investigations after just 6months of attempts at spontaneous conception. In women, there is a decline in fertility rates with age and our concern is not only regarding quantity but also quality of eggs/oocytes.

It is important that the couple are both present for the consultation so that a detailed history can be obtained from both of you and the relevant investigations be carried out without wasting too much time (it is essential that both partners agree on their desire for a child and the relevant timelines). In one third of cases of infertility, a male factor is found (ie. something wrong with the sperm), while in women the 2 main reasons are 1. lack of regular egg production (oligo-/anovulation which most commonly is due to PCOS) and 2. Abnormalities of the female genital tract eg. blocked tubes, fibroids.

After initial investigations, depending on the cause for failure to conceive spontaneously, you may require referral to a fertility specialist for assisted reproductive techniques eg. intrauterine insemination, ovulation induction or in vitro fertilisation.

Most women will be treated for a urinary tract infection at least once in their lifetimes – they are more common in females due to the proximity of the urethra to the vagina & anus as well as the length of the urethra (shorter in women). Symptoms of a UTI include frequent urination, suprapubic discomfort or a burning sensation when passing urine. If left untreated, a lower urinary tract infection can spread up to the kidneys causing fever, chills, loin/flank pain – this can be serious and may warrant hospital admission.

There are certain risk factors that may predispose some women to recurrent UTIs eg. diabetes, obesity, menopause (due to decreased levels of oestrogen in the vagina). If no response to conservative measures of increasing fluid intake, using a urinary alkalise reg. Citro Soda ®, you may require a broad-spectrum antibiotic. If there is no response to the latter, it is advisable that a specimen of urine gets analysed by the laboratory.

The commonest vaginal infections that women will require treatment for are Candidiasis (commonly called thrush) or Bacterial Vaginosis (which is simply an overgrowth of normal vaginal bacterial flora). Neither of these are STIs and are often follow a course of broad-spectrum antibiotics that you may need for an infection elsewhere in your body. You will need to consult a healthcare worker to differentiate between these types of vaginal discharges so the appropriate medication can be prescribed.

Sexually transmitted infections are often asymptomatic until they affect the upper genital tract (uterus and fallopian tubes) where they may cause serious long-term complications eg. chronic pelvic pain, infertility. If you think you may be at risk of having acquired an STI, a series of tests will be done by your doctor (blood and urine samples) or alternatively one may be prescribed a set of three antibiotics that cover most sexually transmitted organisms.

Prolapse of one or more of a woman’s pelvic organs most commonly occurs in the perimenopause/menopausal years due to declining oestrogen levels from the ovary. Other risk factors that predispose women to POP include prolonged labour, difficult deliveries (especially big babies & those assisted by obstetric forceps). Symptoms include the sensation of something bulging out of the vagina or that of lower abdomino-pelvic discomfort. Occasionally these may be associated with bladder symptoms (either involuntary loss of urine or difficulty in passing urine) or difficulty in passing stool.

Depending on your symptoms, age, level of physical activity, co-exisiting medical conditions, past surgery, and degree of prolapse, your gynaecologist may recommend conservative management or surgery.

Any per vaginal bleeding after the menopause (1year after your last menstrual period) in a patient not on hormone therapy, warrants investigation. While the commonest causes of PMB are benign (atrophy ie. thinning of the lining of the female genital tract due to diminishing oestrogen production by the ovaries or polyps of the lining of the uterus/cervix), it is important to exclude female cancers which occur in the older women.

Even if the bleeding stops spontaneously, please consult your gynaecologist as soon as possible so he/she can do a detailed evaluation. Remember to mention if you are taking any medication including hormonal, over-the-counter or natural medication especially any blood-thinning agents.