Hysteroscopy

What is Hysteroscopy?

Hysteroscopy is a small lighted telescope-like camera that is passed through the vagina into the uterus for the diagnosis or treatment of some problems with the uterus.

Why is hysteroscopy done?

Hysteroscopy can be done in the office or in the operating room. Most commonly, it is done in the office to visualize and diagnose causes of abnormal bleeding.

What should I expect during and after the procedure?

During the procedure, a speculum is inserted in the vagina and the thin hysteroscope is fed through the cervix into the uterus, low pressure water is used to inflate the uterine cavity so that the entire inside may be seen. Depending on the reason for your procedure, you may be given some relaxation medicine or some medicine to help open up the cervix for easier passage. After the procedure, you may experience light bleeding or spotting as well as cramping like a menstrual cycle.


LEEP
Loop Electrosurgical Excision Procedure

What is a LEEP and why is is recommended?

A LEEP is a procedure that uses a small loop wire to remove a thin piece of tissue from your cervix. This is recommended for certain women who have had abnormal cervical cancer or pap smear screening tests.


What to expect during and after the procedure?

A LEEP is usually done in the doctor’s office. During the procedure, a speculum is inserted and pain medication is placed around your cervix. A thin wire is used to remove a small piece of tissue. A paste is usually placed in the cervix to decrease any bleeding you may have. After the procedure, it is normal to have spotting or yellowish discharge as well as cramping. You should not place anything in the vagina like tampons or douches and avoid sexual intercourse until your doctor says it is safe to do so. You should call your doctor if you experience fever, heavy bleeding with clots or severe abdominal pain.


Are there risks to LEEP?

LEEP is recommended for severe changes in cervical cells. There may be long term pregnancy complications associated with LEEP. Most women have no problems but, rarely, some may experience early labor with low birth weight babies or cervical scarring which may cause menstrual problems or trouble getting pregnant.


Endometrial Ablation

What is endometrial ablation and why is it done?

Endometrial ablation is done for women with heavy menstrual bleeding, usually when medications have not worked. Electricity is used to destroy a thin layer of the lining of the uterus, or endometrium, to decrease or stop menstrual bleeding. It can be done in the office or in the operating room. A biopsy of the lining of the uterus should be done prior to an ablation to make sure the tissue is normal.

Can I get pregnant after an ablation?

Pregnancy is not common after an ablation but it may happen. If pregnancy does happen, the risk of miscarriage is greatly increased. A woman should have permanent sterilization or use contraception until the age of menopause to prevent pregnancy after an ablation.

What techniques are used to perform an ablation?

Here at Northwest Iowa Surgeons, PC, we use the Novasure endometrial ablation. A probe is inserted into the uterus through the cervix. The tip of the probe expands into a mesh-like device that sends radiofrequency energy into the lining. The energy and heat destroy the endometrial tissue, while suction is applied to remove it.

What can I expect after my procedure?

Some minor symptoms, such as cramping and nausea, may persist for a few days. Many note a thin, watery discharge mixed with blood, which can last a few weeks. The discharge may be heavy for 2–3 days after the procedure.


Urinary incontinence

What is urinary incontinence?

Urinary incontinence simply means leaking urine. Incontinence can range from leaking just a few drops of urine to complete emptying of the bladder.

What are the types of urinary incontinence?

Stress urinary incontinence (SUI) is leaking urine when coughing, laughing, or sneezing. Leaks also can happen when a woman walks, runs, or exercises.

Urgency urinary incontinence is a sudden strong urge to urinate that is hard to stop. Women with this type of urinary incontinence may leak urine on the way to the bathroom. If you have an “overactive bladder” (OAB), it means that you have symptoms of urgency and frequency that may or may not include incontinence.

Mixed incontinence combines symptoms of both SUI and urgency urinary incontinence.

What causes urinary incontinence?

Urinary tract infection (UTI)—UTIs sometimes cause leakage and are treated with antibiotics.

Diuretic medications, caffeine, or alcohol—Incontinence may be a side effect of substances that cause your body to make more urine.

Pelvic floor disorders—These disorders are caused by weakening of the muscles and tissues of the pelvic floor and include urinary incontinence, accidental bowel leakage, and pelvic organ prolapse.

Constipation—Long-term constipation often is present in women with urinary incontinence, especially in older women.

Neuromuscular problems—When nerve (neurologic) signals from the brain to the bladder and urethra are disrupted, the muscles that control those organs can malfunction, allowing urine to leak.

Anatomical problems—The outlet of the bladder into the urethra can become blocked by bladder stones or other growths.

What lifestyle changes can help decrease urine leakage?

Lose weight. In overweight women, losing even a small amount of weight (less than 10% of total body weight) may decrease urine leakage.

Manage your fluid intake. If you have leakage in the early morning or at night, you may want to limit your intake of fluids several hours before bedtime. Limiting the amount of fluids you drink also may be useful (no more than 2 liters total a day). Limiting alcohol and caffeine may be helpful as well.

Train your bladder. The goal of bladder training is to learn how to control the urge to empty the bladder and increase the time span between urinating to normal intervals (every 3–4 hours during the day and every 4–8 hours at night).

What types of exercise and physical therapy can help treat urinary incontinence?

Kegel exercises can help strengthen the pelvic muscles. These exercises are helpful for all types of incontinence. Biofeedback is a training technique that may help you locate the correct muscles. In one type of biofeedback, sensors are placed inside or outside the vagina that measure the force of pelvic muscle contraction. When you contract the right muscles, you will see the measurement on a monitor.

What devices are available to help treat urinary incontinence?

A pessary is a device that is inserted into the vagina to treat pelvic support problems and SUI. Pessaries support the walls of your vagina to lift the bladder and urethra. They come in many shapes and sizes. Usually you can insert and remove a support pessary yourself. Pessaries may provide relief of symptoms without surgery. An over-the-counter tampon-like device also is available that is designed specifically to help prevent bladder leaks.

What medications are available to help treat urinary incontinence?

Drugs that control muscle spasms or unwanted bladder contractions can help prevent leakage from urgency urinary incontinence and relieve the symptoms of urgency and frequency.

Mirabegron is a drug that relaxes the bladder muscle and allows the bladder to store more urine. This drug is used to treat urgency urinary incontinence and relieve the symptoms of urgency and frequency.

Injection of a drug called onabotulinumtoxinA into the muscle of the bladder helps stop unwanted bladder muscle contractions. The effects last for about 3–9 months.

What types of surgery are available to treat SUI?

Slings—Different types of slings, such as those made from your own tissue or synthetic materials, can be used to lift or provide support for the urethra. The synthetic midurethral sling is the most common type of sling used to correct SUI. This sling is a narrow strap made of synthetic mesh that is placed under the urethra.

Colposuspension—Stitches are placed on either the side of the bladder neck and attached to nearby supporting structures to lift up the urethra and hold it in place.

If surgery is not an option for you or has not worked for your SUI, urethral bulking may help. A synthetic substance is injected into the tissues around the urethra. The substance acts to “plump up” and narrow the opening of the urethra, which may decrease leakage.

What procedures are available to treat urgency urinary incontinence?

Sacral neuromodulation—This is a technique in which a thin wire is placed under the skin of the low back and close to the nerve that controls the bladder. The wire is attached to a battery device placed under the skin nearby. The device sends a mild electrical signal along the wire to improve bladder function.

Percutaneous tibial nerve stimulation (PTNS)—PTNS is a procedure that is similar to acupuncture. In PTNS, a slender needle is inserted near a nerve in the ankle and connected to a special machine. A signal is sent through the needle to the nerve, which sends the signal to the pelvic floor. PTNS usually involves weekly 30-minute office sessions for a few months.

Permanent sterilization

Sterilization means a permanent form of birth control. For women, this is tubal sterilization, for men this is a vasectomy. There are several different types of sterilization for women, all are offered at Northwest Iowa Surgeons. All are considered permanent and not meant to be reversed. None protect against sexually transmitted infections.

Postpartum tubal ligation- this is done just after the birth of a baby. If a woman has had a vaginal delivery, a small incision is made under the navel and portions of the fallopian tubes are removed. If the baby is born via cesarean section, portions of each fallopian tube are removed at the time of surgery.

Laparoscopic tubal ligation is done in the operating room under anesthesia. A small incision is made in the navel and one other down near the pubic hair line. A thin camera is used and clips are placed across each tube to prevent the sperm and egg from coming together. This type of sterilization is effective right away. Following women for several years after this type of surgery shows it to be highly effective but there is a risk of tubal or ectopic pregnancy which can be a medical emergency. Pregnancy rates following this type of sterilization are between 2 and 10 women out of 1,000.

Hysteroscopic sterilization is usually done in the office with little to no need for medication. A small camera is passed through the cervix and into the vagina. Sterile devices are placed into each tubal opening. These devices cause scarring that allow the tubes to close. It is not immediately effective. A woman must use back-up birth control for three months until an x-ray study can be done (hysterosalpingogram) to see that the tubes are closed off. After following women for more than 5 years, there is a less than 5 in 1,000 risk of failure.

Laparoscopic salpingectomy is surgery that uses small incisions and a camera to remove both fallopian tubes. It is done in the hospital under anesthesia. It will likely involve a slightly longer surgery time, one more incision and a small increased risk of complication as compared to laparoscopic tubal ligation with clips. It may be offered as current research suggests that removal of the entire fallopian tube may reduce some women’s risk of ovarian cancer at an older age although research is still ongoing.


Hysterectomy

What is a hysterectomy?

Hysterectomy is surgery to remove the uterus. It is a very common type of surgery for women in the United States. Removing your uterus means that you can no longer become pregnant.

Why is hysterectomy done?

Hysterectomy is used to treat many women’s health conditions. Common reasons for hysterectomy include abnormal uterine bleeding, fibroids, prolapse, endometriosis, gynecologic cancer, chronic pelvic pain.

What structures are removed during a hysterectomy?

In a total hysterectomy, the uterus and cervix are removed. In a supracervical hysterectomy, only the body of the uterus is removed while the cervix remains in place. You will still need pap smears following a supracervical hysterectomy. You and your surgeon will discuss the possible risks and benefits of removing your fallopian tubes (salpingectomy) or ovaries (oophorectomy).

What are the different ways hysterectomy can be performed?

A hysterectomy can be done in different ways: through the vagina, through the abdomen (like a cesarean), or with laparoscopy. Laparoscopic hysterectomies may be performed with the daVinci surgical robot which is an advanced form of laparoscopy. The choice will depend on why you are having the surgery and other factors. At Northwest Iowa Surgeons, more than 99% of hysterectomies are performed minimally invasively or via the laparoscopic or vaginal route.

What should I expect after having a hysterectomy?

You can expect to have some pain for the first few days after the surgery. You will be given medication to relieve pain. You will have bleeding and discharge from your vagina for several weeks. Sanitary pads can be used after the surgery. Constipation is common after most hysterectomies. Some women have temporary problems with emptying the bladder after a hysterectomy. Other effects may be emotional. It is not uncommon to have an emotional response to hysterectomy. You may feel depressed that you are no longer able to bear children, or you may be relieved that your former symptoms are gone.

What are some important things I should know about recovery?

Follow your health care provider’s instructions. Be sure to get plenty of rest, but you also need to move around as often as you can. Take short walks and gradually increase the distance you walk every day. You should not lift heavy objects until your doctor says you can. Do not put anything in your vagina during the first 6 weeks. That includes douching, having sex, and using tampons.


Prolapse

What is pelvic organ prolapse?

Pelvic organ prolapse is when one or more of the pelvic organs drop from their normal position. Prolapse can involve the uterus or the vaginal vault for women who have had a hysterectomy, the front wall of the vagina or the bladder (cystocele) and the back wall of the vagina or the rectum (rectocele) as well as the pouch between the rectum and the back wall of the uterus involving the small intestine (enterocele).

What are the symptoms of pelvic organ prolapse?

In severe prolapse, the woman can see or feel a bulge of tissue at or past the vaginal opening. Most women have mild prolapse and may experience a feeling of fullness or heaviness in the pelvis, painful or uncomfortable sex, difficulty urinating or passing bowel movements.

How is pelvic organ prolapse treated?

If you do not have any symptoms or if your symptoms are mild, you do not need any special follow-up or treatment beyond having regular checkups. If you have symptoms, prolapse may be treated with or without surgery.

What are the nonsurgical treatments for pelvic organ prolapse?

Often the first nonsurgical option tried is a pessary. This device is inserted into the vagina to support the pelvic organs. Targeting specific symptoms may be another option. Kegel exercises may be recommended in addition to symptom-related treatment to help strengthen the pelvic floor. Weight loss can decrease pressure in the abdomen and help improve overall health.

When should I consider surgery to treat pelvic organ prolapse?

If your symptoms are severe and disrupt your life, and if nonsurgical treatment options have not helped, you may want to consider surgery.

What are the types of surgery for pelvic organ prolapse?

In general, there are two types of surgery; obliterative surgery and reconstructive surgery.

Obliterative surgery narrows or closes off the vagina to provide support for prolapsed organs. Sexual intercourse is not possible after this procedure.

Reconstructive surgery reconstructs the pelvic floor with the goal of restoring the organs to their original position. Some types of reconstructive surgery are done through an incision in the vagina. Others are done through an incision in the abdomen or with laparoscopy.

What are the types of reconstructive surgery?

Fixation or suspension using your own tissues (uterosacral ligament suspension and sacrospinous fixation)—These procedures are performed through the vagina and may involve less recovery time than those performed through the abdomen. A procedure to prevent urinary incontinence may be done at the same time.

Anterior and posterior colporrhaphy—Because these procedures are performed through the vagina, recovery time usually is shorter than with procedures performed through the abdomen.

Sacrocolpopexy and sacrohysteropexy—These abdominal procedures may result in less pain during sex than procedures performed through the vagina.

Surgery using vaginally placed mesh—Mesh placed through the vagina has a significant risk of complications, including mesh erosion, pain, and infection. Because of these risks, vaginally placed mesh for pelvic organ prolapse usually is reserved for women in whom previous surgery has not worked, who have a medical condition that makes abdominal surgery risky, or whose own tissues are too weak to repair without mesh.

What is involved in recovery after surgery to treat pelvic organ prolapse?

Recovery time varies depending on the type of surgery. You usually need to take a few weeks off from work. For the first few weeks, you should avoid vigorous exercise, lifting, and straining. You also should avoid sexual intercourse for several weeks after surgery.


Menopausal symptoms and hormone therapy

Types of Hormone Therapy

Hormone therapy can help relieve the symptoms of perimenopause and menopause. Hormone therapy means taking estrogen and, if you have never had a hysterectomy and still have a uterus, progestin. Progestin is a form of progesterone. Taking progestin helps reduce the risk of cancer of the uterus that occurs when estrogen is used alone. If you do not have a uterus, estrogen is given without progestin. Estrogen plus progestin sometimes is called “combined hormone therapy” or simply “hormone therapy.” Estrogen-only therapy sometimes is called “estrogen therapy.”

Risks and Benefits

Systemic estrogen therapy (with or without progestin) has been shown to be the best treatment for the relief of hot flashes and night sweats.

Systemic and local types of estrogen therapy relieve vaginal dryness.

Systemic estrogen protects against the bone loss that occurs early in menopause and helps prevent hip and spine fractures.

Combined estrogen and progestin therapy may reduce the risk of colon cancer.
As with any treatment, hormone therapy is not without risks. Hormone therapy may increase the risk of certain types of cancer and other conditions:
Estrogen therapy causes the lining of the uterus to grow and can increase the risk of uterine cancer. Adding progestin decreases the risk of uterine cancer.

Combined hormone therapy is linked to a small increased risk of heart attack. This risk may be related to age, existing medical conditions, and when a woman starts taking hormone therapy. Some research suggests that for women who start combined therapy within 10 years of menopause and who are younger than 60 years, combined therapy may protect against heart attacks. However, combined hormone therapy should not be used solely to protect against heart disease.

Combined hormone therapy and estrogen-only therapy are associated with a small increased risk of stroke and deep vein thrombosis (DVT). Forms of therapy not taken by mouth (patches, sprays, rings, and others) have less risk of causing DVT than those taken by mouth.

Combined hormone therapy is associated with a small increased risk of breast cancer. Currently, it is recommended that women with a history of hormone-sensitive breast cancer try nonhormonal therapies first for the treatment of menopausal symptoms.

There is a small increased risk of gallbladder disease associated with estrogen therapy with or without progestin. The risk is greatest with forms of therapy taken by mouth.

Side Effects

Combined hormone therapy may cause vaginal spotting. Some women may have heavier bleeding like that of a menstrual period. If you are postmenopausal, it is important to tell your health care provider if you have bleeding. Although it is often an expected side effect of hormone therapy, it also can be a sign of endometrial cancer. All bleeding after menopause should be evaluated.

Other side effects reported by women who take hormone therapy include fluid retention and breast soreness. This soreness usually lasts for a short time.

Other Medications

An antidepressant is available for the treatment of hot flashes. Gabapentin, an antiseizure medication, and clonidine, a blood pressure medication, are prescription drugs that can be prescribed to reduce hot flashes and ease sleep problems associated with menopause. Selective estrogen receptor modulators (SERMs) are drugs that act on tissues that respond to estrogen. Two drugs that contain SERMs are available for the relief of hot flashes and pain during intercourse caused by vaginal dryness.

Plant-Based Alternatives

Plants and herbs that have been used for menopause symptoms include soy, black cohosh, and Chinese herbal remedies. Only a few of these substances have been studied for safety and effectiveness. Also, the way that these products are made is not regulated by the U.S. Food and Drug Administration (FDA). There is no guarantee that the product contains safe ingredients or effective doses of the substance. If you do take one of these products, be sure to let your health care provider know.

Bioidentical Hormones

Bioidentical hormones come from plant sources. They include commercially available products and compounded preparations. Compounded bioidentical hormones are made by a compounding pharmacist from a health care provider’s prescription. Compounded drugs are not regulated by the FDA. They have the same risks as FDA-approved hormone therapies, and they also may have additional risks because of the way they are made. There is no scientific evidence that compounded hormones are safer or more effective than standard hormone therapy.

Follow-up

If you choose to take hormone therapy, regular follow-up is important. Your need to take hormone therapy may change. Benefits and risks also may change over time. Your health care provider should assess your continued use of hormone therapy on a yearly basis. At your yearly visits, tell your health care provider if you have any new symptoms. Let your health care provider know how well the hormone therapy is working. Report any side effects, especially vaginal bleeding, to your health care provider right away.


Vulvar skin disorders

What is the vulva?

The external female genital area is called the vulva. The outer folds of skin are called the labia majora and the inner folds are called the labia minora.

What is folliculitis?

Folliculitis appears as small, red, and sometimes painful bumps caused by bacteria that infect a hair follicle. It can occur on the labia majora. This can happen because of shaving, waxing, or even friction. Folliculitis often goes away by itself. Attention to hygiene, wearing loose clothing, and warm compresses applied to the area can help speed up the healing process. If the bumps do not go away or they get bigger, see your health care provider. You may need additional treatment.

What is contact dermatitis?

Contact dermatitis is caused by irritation of the skin by things such as soaps, fabrics, or perfumes. Signs and symptoms can include extreme itching, rawness, stinging, burning, and pain. Treatment involves avoidance of the source of irritation and stopping the itching so that the skin can heal. Ice packs or cold compresses can reduce irritation. A thin layer of plain petroleum jelly can be applied to protect the skin. Medication may be needed for severe cases.

What is lichen simplex chronicus?

Lichen simplex chronicus may be a result of contact dermatitis or other skin disorder that has been present for a long time. Thickened, scaly areas called “plaques” appear on the vulvar skin. These plaques cause intense itching that may interfere with sleep. Treatment involves stopping the “itch-scratch” cycle so that the skin can heal. Steroid creams often are used for this purpose. The underlying condition should be treated as well.

What is lichen sclerosus?

Lichen sclerosus is a skin disorder that can cause itching, burning, pain during sex, and tears in the skin. The vulvar skin may appear thin, white, and crinkled. White bumps may be present with dark purple coloring. A steroid cream is used to treat lichen sclerosus.

What is lichen planus?

Lichen planus is a skin disorder that most commonly occurs on the mucous membranes of the mouth. Occasionally, it also affects the skin of the genitals. Itching, soreness, burning, and abnormal discharge may occur. The appearance of lichen planus is varied. There may be white streaks on the vulvar skin, or the entire surface may be white. There may be bumps that are dark pink in color.

Treatment of lichen planus may include medicated creams or ointments, vaginal tablets, prescription pills, or injections. This condition is difficult to treat and usually involves long-term treatment and follow-up.

What is vulvodynia?

Vulvodynia means “vulvar pain.” The pain can occur when the area is touched or it can occur without touch. There are two types of vulvodynia: generalized and localized (see FAQ127 “Vulvodynia”). With generalized vulvodynia, the pain occurs over a large area of the vulva. With localized vulvodynia, the pain is felt on a smaller area, such as the vestibule. Vulvodynia usually is described as burning, stinging, irritation, or rawness. The skin of the vulva usually looks normal. A variety of methods are used to treat vulvodynia, including self-care measures, medications, dietary changes, biofeedback training, physical therapy, sexual counseling, or surgery.

What is genitourinary syndrome of menopause?

Genitourinary syndrome of menopause is a group of signs and symptoms caused by the decreased estrogen levels that occur in perimenopause and menopause. Signs and symptoms include soreness, irritation, and dryness. Pain may occur during sexual intercourse. The vulva becomes more sensitive to irritants. Infections may occur more easily. In severe cases, vulvar skin may crack and bleed. This condition is treated with medications containing estrogen that are applied to the skin or inserted into the vagina.

What is vulvar intraepithelial neoplasia (VIN)?

Vulvar intraepithelial neoplasia (VIN) is the presence of abnormal vulvar cells that are not yet cancer. VIN often is caused by human papillomavirus (HPV) infection. Signs and symptoms include itching, burning, or abnormal skin that may be bumpy, smooth, or a different color like white, brown, or red. VIN should be treated to prevent the development of cancer. VIN can be treated with a cream that is applied to the skin, laser treatment, or surgery. The HPV vaccine that protects against four types of HPV and the HPV vaccine that protects against nine types of HPV can help prevent VIN caused by these HPV types.

What causes vulvar cancer?

Vulvar cancer can be caused by infection with HPV. Other forms of cancer that can affect the vulva include melanoma (skin cancer) or Paget disease. Paget disease of the vulva may be a sign of cancer in another area of the body, such as the breast or colon. Signs and symptoms may include itching, burning, inflammation, or pain. Other symptoms of cancer include a lump or sore on the vulva, changes in the skin color, or a bump in the groin. The type of treatment depends on the stage of cancer. Surgery often is needed to remove all cancerous tissue. Radiation therapy and chemotherapy also may be needed in addition to surgery.

What self-care measures can help prevent or clear up vulvar problems?

Keep your vulva clean by rinsing with warm water and gently patting, not rubbing, it dry.

Do not wear tight-fitting pants or underwear. Wear only cotton underwear.

Do not wear pantyhose (unless they have a cotton crotch).

Do not use pads or tampons that contain a deodorant or a plastic coating.

Do not use perfumed soap or scented toilet paper.

Do not douche or use feminine sprays or talcum powders.