ENDOMETRIOSIS

Endometriosis is an often painful disorder of the female reproductive system. The tissue that lines the inside of the uterus is called the endometrium. In endometriosis the lining grows outside the uterus, most commonly on the fallopian tubes and ovaries. Rarely it can spread beyond that onto the bladder, bowel, vagina etc.

WHAT HAPPENS IN ENDOMETRIOSIS

During your menstrual cycle, hormones signal the lining of your uterus to thicken to prepare for a possible pregnancy. If a pregnancy does not occur, the hormone levels decrease, causing the thickened lining to shed. This produces bleeding that exists through your body through the vagina-your monthly period.

When the lining of the uterus is located elsewhere it continues to act in the same way - the lining thickens, breaks down and bleeds. But it has nowhere to go or exit the body. So it get trapped.

Trapped blood may lead to the growth of cyst - CHOCOLATE CYSTS. Cysts cause scar tissue and adhesions - that binds organs together.

This causes pain and infertility.

SYMPTOMS OF ENDOMETRIOSIS 
1. PAIN - before and during periods. Can be very severe and increases over time.
2. INFERTILITY 
3. PAIN WITH INTERCOURSE 
4. OTHERS - pain with bowel movements or urination
                     - bloating
                     - nausea and vomiting

• Endometriosis is most likely to occur in women who haven’t had children - Some have an inherited tendency
•  It usually takes several years after the onset of menstruation (menarche) to develop
• When menstruation ends permanently with menopause or temporarily with pregnancy, the symptoms stop.

WHEN TO SEE A DOCTOR 

Severe pain during your periods or a history of infertility.
Endometriosis can be diagnosed by

• ULTRASOUND - either abdominally or trans-vaginal.
• LAPAROSCOPY - sometimes during a routine or a diagnostic laparoscopy the doctor can directly visualise the cysts.

WHAT ARE YOUR TREATMENT OPTIONS IF YOU HAVE ENDOMETRIOSIS

If your symptoms are mild and you are not planning a pregnancy anytime soon your doctor may recommend

•     Pain Medications 
•     Hormone Therapy 

LAPAROSCOPIC CONSERVATIVE SURGERY 

• If you are trying to get pregnant, laparoscopic surgery to remove the cysts and scar tissue will increase the chance of your success. 
• If you have endometriosis that causes severe pain you may also benefit from your surgery.

LAPAROSCOPIC HYSTERECTOMY

In severe cases of endometriosis, a total laparoscopic hysterectomy and the removal of both ovaries may be the best treatment. Hysterectomy alone is also effective, but removing the ovaries ensures that endometriosis will not return.

RASHMI HOSPITAL TEAM 
At Rashmi Hospital we evaluate each patient on an individual basis to offer you options regarding endometriosis - especially with pain management.

WHAT CAUSES ENDOMETRIOSIS

The cause is really known but some theories have been put forward.

• The retrograde menstruation theory - suggests that during menstruation some of the menstrual tissue backs up through the fallopian tubes and spills in the abdomen and grows. 
• Endometrial Cell Transport - through the blood system or lymph system
• Genetic Theory - same families have a predisposition
• Immune system disorder 
• Surgical Tear Implantation

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MYOMECTOMY

A myomectomy is a surgery done to remove uterine fibroids while retaining the uterus, done in a women during child bearing age.

SYMPTOMS - uterine fibroids can cause.

•     Heavy periods
•     Painful periods
•     Infertility
•     Pelvic pressure
•     Increase in abdominal girth

AIM - the aim of a myomectomy is to remove the fibroids, and hence relive the symptoms and improve the chances of fertility.

TECHNIQUES OF MYOMECTOMY
1. Laparoscopic myomectomy - The surgery is performed through a few small incisions made on the abdomen. The fibroid is cut into pieces (morcellation) and removed through a small incision. Sometimes the fibroid is put into a bag (endo bag) and in-bag morcellation is done.

2.HYSTEROSCOPIC MYOMECTOMY - A fibroid that protrudes into the uterine cavity is called a submucosal fibroid. This is removed (resected) through a hysteroscope inserted through the vagina and cervix.

3.ABDOMINAL MYOMECTOMY - A large open cut is made in the abdomen.

WHAT TO EXPECT

    1.You will need to come in the morning of the surgery on an empty stomach.

   2. You will be prepared for general anaesthesia.

    3.Depending on the procedure you can go home late evening (hysteroscopic myomectomy) or stay overnight (laparoscopic myomectomy)

   4. As we perform only minimally invasive surgery here at Rashmi Hospital you will have.

•     Less pain
•     Shorter hospital stay
•     Quicker recovery
•     A much smaller scar; as compared to an open procedure.

FERTILITY AND LAPAROSCOPIC MYOMECTOMY
Women who have undergone a laparoscopic myomectomy have a good chance of improved fertility. Results are better in younger women with only 1 fibroid.

We advise waiting 6 months before planning a pregnancy, this gives time for the uterus to heal.

PREGNANCY RISKS AFTER A MYOMECTOMY
As the uterus has been operated upon, the scar on the uterus makes that area weak, which can rupture during labor. A cesarean section may be advised around 38 weeks of pregnancy.

WILL THE FIBROIDS COME BACK
Yes, they can come back especially in

•     Older women
•     Women who do not plan a pregnancy fast
•     Women who have had multiple fibroids

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HYSTEROSCOPY

Hysteroscopy is a surgical procedure where a small telescope (the size of a pencil) is used to inspect the inside of the uterus. A camera is attached to the end of the telescope and the image is viewed on a video monitor. Surgery is carried out while looking at the monitor.

DIAGNOSTIC HYSTEROSCOPY  is performed with a smaller instrument. It can be combined with a D & C (Dilatation and curettage) or an endometrial sampling.

OPERATIVE HYSTEROSCOPY.
When a problem is diagnosed during a diagnostic hysteroscopy it can be cleared or operated upon at the same time.

The operative hysteroscope is larger and has parts which allows the physician to insert operating tools like scissors, cautery or a laser.

PROBLEMS THAT CAN BE TREATED

•     Uterine polyps.
•     Uterine septum.
•     Adhesions (a scar tissue) in the uterus.
•     Same types of tubal block.
•     Uterine fibroids.
•     An old IUCD that is ‘lost’.

ROLE OF SIMULTANEOUS LAPAROSCOPY and HYSTEROSCOPY.

The surgeon may advise a simultaneous laparoscopy

•     In infertility patients to check the potency of the fallopian tubes
•     When a bicornuate (double) uterus is suspected.
•     While doing tubal cannulation in patients with blocked tubes.
•     To aid in the prevention of uterine perforation if excessive hysteroscopy surgery is performed.

WHAT TO EXPECT.

•     You will come in the morning of surgery on an empty stomach.
•     You should be able to go home in the evening.
•     In general, you will be able to return to normal activity within 1-2 days.
•     Complications are infrequent, may be same mild cramping. 

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MYTHS OF A HYSTERECTOMY

1.I will put on weight and have an early menopause.

Mood changes, dry skin etc are a sign of menopause. Menopause occurs when both the ovaries are removed and the production of the hormones stop. In a hysterectomy only the uterus is removed. Here in Rashmi Hospital, we retain the ovaries even in post menopausal women.

2.Along recovery period with bed rest.

At Rashmi Hospital all women who undergo a laparoscopic hysterectomy are home the next day and back to work or all normal activities within a week to 10 days.

3.A hysterectomy is very painful.

As we perform only laparoscopic hysterectomy, the cuts are very small and not painful. You can walk by evening and eat normal food too.

4.I will have a huge ugly scar.

No, a laparoscopic hysterectomy is done through a few small incisions (a cuts) which heal very well.

5.Sex is not enjoyable.

On the contrary some women enjoy sex more because.

•     The fear of pregnancy is no longer there.
•     Any condition like a deep fibroid which was causing painful intercourse is eliminated.

6.I will have back pain.

This is again a sign of menopause when women do not take calcium. Since your ovaries are left intact you will not experience back pain.

WHAT HAPPENS TO ME AFTER A HYSTERECTOMY.

You will be relieved of your symptoms like heavy periods, painful periods etc.

The only change that you will see in your body is

•     You will no longer have your periods.
•     You will not be able to have a baby.

 

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Hysterectomy: Types, Risks And Recovery

Hysterectomy:

Hysterectomy, a medical term for the removal of the uterus, is commonly performed on patients ailing from uterine cancer, gynaecological cancer, uterine prolapse, persistent vaginal bleeding, chronic pelvic pain, fibroids, or endometriosis.

There are two ways of performing a Hysterectomy: Open and Laparoscopic.

Open Hysterectomy, although still practiced by many doctors, has some drawbacks. For one, it requires the doctor to make a large incision across the belly, due to which the patient has to spend 2-3 days in hospital care. Two, it leaves a scar on the body.

Laparoscopic Hysterectomy, on the other hand, is far less invasive. Instead of one big incision, the doctor makes a few incisions of about a centimetre each near the abdomen through which he lets in a laparoscope having a camera. The images taken by the camera are then projected to a high-resolution screen for the doctor to view and perform the surgery.

There are some clear advantages to Laparoscopic Hysterectomy, which include:

• Less blood loss
• Less scarring
• Less post-operative pain; and
• Quick recovery

There are several surgeons who continue to insist that Laparoscopic Hysterectomy is not an option where the size of the uterus is too large. A surgeon skilled in it, may, however, want to disagree to the view.

The important thing really is for patients to find a surgeon with the necessary skill and the experience - and, no less, having access to the right equipment - to carry out a laparoscopic hysterectomy.

  Hysterectomy can be done in several ways:

• Partial hysterectomy, which removes the uterus leaving the cervix in place.
• Total hysterectomy, which removes both the cervix and the uterus
• Hysterectomy and bilateral salpingo-oophorectomy, which remove the uterus along with the ovaries, fallopian tubes, and cervix.
• Radical Hysterectomy, which removes the upper portion of the vagina, the surrounding tissues and also the lymph nodes.

Are there any risks related to Hysterectomy?

Hysterectomy is a relatively safe procedure. If at all some complications do arise during surgery, they can be controlled and treated.

The risks of performing a hysterectomy are:

• Urinary tract may be damaged in a few cases; and
• Bladder and rectum may also be damaged.

Other complications include:

• Blood clots
• Infections
• Excessive bleeding; and
• Adverse reactions to anaesthesia

Recovery

After hysterectomy, a patient is kept in the recovery room for a few hours under medical observation. Within a day or two of the surgery, she is fit to start walking.                    

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