Gynaecological services
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Dr Rahimpanah’s areas of special interest include:
• Minimal access surgery o laparoscopic-assisted vaginal hysterectomy o laparoscopic resection of endometriosis o laparoscopic adnexal surgery o hysteroscopic endometrial resection and Endometrial ablation• Vaginal and Pelvic floor reconstructive surgery• Female urinary problems• Medical and Surgical management of Menstrual disorders and Endometriosis• Contraception• Management of abnormal Pap-smear
These are some General information about conditions you may have or procedures you may require
ENDOMETRIOSIS
What is endometriosis?
Endometriosis is a very common condition where cells of the lining of the womb (the endometrium) are found elsewhere, usually in the pelvis and around the womb, ovaries and fallopian tubes. It mainly affects women during their reproductive years. It can affect women from every social group and ethnicity. Endometriosis is not an infection and it is not contagious. Endometriosis is not cancer.
What could endometriosis mean for me?
The main symptoms of endometriosis are pelvic pain, pain during or after sex, painful, sometimes heavy periods and, for some women, problems with getting pregnant.
Endometriosis can affect many aspects of a woman’s life including her general physical health, emotional wellbeing and daily routine.
Endometriosis is common and many women may have no symptoms. 1 in 9 women, in Australia, live with endometriosis
Endometriosis is a long-term condition which affects women of all ages during their reproductive years (from the onset of menstrual periods to the menopause). It affects women from all social and ethnic groups.
Women who do experience symptoms may have one or more conditions:
• painful periods (dysmenorrhoea) which do not respond to over-the-counter pain relief. Some women have heavy periods.• pain during or after sexual intercourse (dyspareunia)• lower abdominal pain• pelvic pain which can be long-term• difficulty in getting pregnant or infertility• pain related to the bowels and bladder (with or without abnormal bleeding)• long-term fatigue.
Some women do not have any symptoms at all.
Pain is a common symptom of endometriosis. The pain can be a dull ache in the lower abdomen, pelvis or lower back. Pain affects each woman differently: where it hurts, when it hurts and how much it hurts. The pain, and the effects of endometriosis, can make you feel depressed.
Most women with endometriosis get pain in the area between their hips (known as the pelvis) and the tops of their legs. Some women get pain only at certain times, such as during their periods, when they have sex or when they open their bowels. Other women have pain all the time.
Some women with endometriosis become pregnant easily while others have difficulty getting pregnant. The pain may get better during pregnancy and then recur after the birth of the baby. Some women find that their pain resolves without any treatment.
What causes endometriosis?
During the menstrual cycle, under the influence of the female hormones estrogen and progesterone, the lining (endometrium) of the womb thickens in readiness for a fertilised egg. If pregnancy does not occur, the lining is shed as a period.
Endometriosis occurs when the cells of the lining of the womb are found in other parts of the body, usually the pelvis. Each month this tissue outside the womb thickens and breaks down and bleeds in the same way as the lining of the womb. This internal bleeding into the pelvis, unlike a period, has no way of leaving the body. This causes inflammation, pain and damage to the reproductive organs.
Reproductive areas where endometriosis can be found see the image above:
Endometriosis commonly occurs in the pelvis. It can be found:
• on the ovaries where it can form cysts (often referred to as ‘chocolate cysts’)• in or on the fallopian tubes• almost anywhere on, behind or around the womb• in the peritoneum (the tissue that lines the abdominal wall and covers most of the organs in the abdomen).
Less commonly, endometriosis may occur on the bowel and bladder, or deep within the muscle wall of the uterus (adenomyosis). It can also rarely be found in other parts of the body.
Why does endometriosis occur?
It is not yet known why endometriosis occurs. A number of theories have been suggested but none has been proved. The most commonly accepted theory is that, during a period, light ‘backward’ bleeding carries tissue from the womb to the pelvic area via the fallopian tubes. This is called ‘retrograde menstruation’.
How soon can I expect to get a diagnosis?
For many women, it can take years to get a diagnosis. Doctors say that this is because:• no one symptom or set of symptoms can definitely confirm a diagnosis of endometriosis• the symptoms of endometriosis are common and could be caused by a number of other conditions such as irritable bowel syndrome (IBS) and pelvic inflammatory disease (PID)• different women have different symptoms• some women have no symptoms at all.
There is no simple test for endometriosis. The only way to make a definite diagnosis is by a small surgical operation known as laparoscopy (see What treatment can I get?). This is not performed on every woman.
If you have painful periods and no other symptoms, your doctor may suggest that you try pain relief before having further surgical investigation or treatments.
Living without a diagnosis can be distressing. Many women may fear the worst about why they are in pain or why they are having problems becoming pregnant.
What happens when I see a specialist?
At your appointment, you may be asked specific questions about your periods and your sex life. It is important that you provide as much information as possible, as this will help your doctor find the correct diagnosis. You may find it helpful to write down your symptoms beforehand and take your notes along to the appointment with you. In this way, you will be sure to provide all the information required. Some women find it helpful to take a friend or partner along with them as well.
You should also have an opportunity to ask.
Your gynaecologist may examine your pelvic area, this will include an internal examination. Your doctor will discuss the best time to do this. This may be when you are having your period. If you have concerns about this, you should have an opportunity to discuss them.
What types of tests might I be offered?
You should be given full information about the tests that are available. These may include:
Ultrasound
You may be offered a scan. This can identify whether there is an endometriosis cyst in the ovaries. This may include an internal ultrasound. A normal scan does not rule out endometriosis.
Laparoscopy
For most women, having a laparoscopy is the only way to get a definite diagnosis; because of this, it is often referred to as the ‘gold standard’ test. A laparoscopy is a small operation which is carried out under general anaesthesia. A small cut is made in your abdomen near your tummy button (navel), then a telescope (known as a laparoscope), which is about the width of a pen, is inserted. This allows the gynaecologist to see the pelvic organs clearly and look for any endometriosis. This is usually carried out as day surgery.
As with any surgical procedure, there are risks and benefits. These will be fully explained to you when you are offered the test.
If you have a laparoscopy, you should be given full information about your results.
Making a decision about treatment
You should be given full information about your options for treatment. This should also include information about the risks and benefits of each option.
Several factors may influence your decision about treatment. These include:
• how you feel about your situation• your age• whether your main symptom is pain or problems getting pregnant• whether you want to become pregnant – some hormonal treatments which help to reduce the pain will stop you from becoming pregnant• how you feel about surgery• what treatment you have had before• how effective certain treatments are.
You may decide that no treatment is the best way forward. This could be because your symptoms are mild, you have not had problems getting pregnant or you are nearing the menopause, when symptoms may get better.
What treatment can I get?
The options for treatment may be:
Pain relief
Pain-relieving drugs reduce inflammation and help to ease the pain.
Hormone treatments
There is a range of hormone treatments to stop or reduce ovulation (the release of an egg) to allow the endometriosis to shrink or disappear.The hormonal methods below are contraceptives and will prevent you from becoming pregnant:
• The combined oral contraceptive (COC) pill or patchThese contain the hormones estrogen and progestogen and work by preventing ovulation and can make your periods lighter, shorter and less painful.• The intrauterine system (IUS): this is a small T-shaped device which releases the hormone progestogen. This helps to reduce the pain and makes periods lighter. Some women get no periods at all.The hormonal methods below are non-contraceptive, so contraception will be needed if you do not want to become pregnant:• Use of hormonal progestogens or testosterone derivatives• GnRH agonists – these drugs prevent estrogen being produced by the ovaries and cause a temporary and reversible menopause.
Surgery
Surgery can be used to remove areas of endometriosis. Surgery including hysterectomy does not always successfully remove the endometriosis. There are different types of surgery, depending on where the endometriosis is and how extensive it is. How successful the surgery is can vary and you may need further surgery. Your gynaecologist will discuss this with you before any surgery.
• Laparoscopic surgery
The gynaecologist removes patches of endometriosis by destroying them or cutting them out.
• Laparotomy
If the endometriosis is severe and extensive, you may be offered a laparotomy. This is major surgery which involves a cut in the abdomen, usually in the bikini line.
• Hysterectomy
Some women have surgery to remove their ovaries or womb (a hysterectomy). Having this surgery means that you will no longer be able to have children after the operation. Depending upon your own situation, your doctor should discuss hormone replacement therapy (HRT) with you if you have your ovaries removed.
What if I am having difficulty getting pregnant?
Getting pregnant can be a problem for some women with endometriosis. Your doctor will provide you with full information about your options such as assisted conception.
Are there any side effects?
You will be given full detailed information about the risks and benefits of any investigation, surgical procedure and treatment suggested. The side effects will vary from woman to woman.
Living with endometriosis
Not all cases of endometriosis can be cured and for some women, there is no long-term treatment that helps. With support, many women find ways to live with and manage this condition.
Support
Support organisations provide invaluable counselling, support and advice
Complementary therapies
Complementary therapies include reflexology, traditional Chinese medicine, herbal treatments and homoeopathy. They may be effective at relieving pain. Many women have found that dietary changes such as eliminating certain food types, such as dairy or wheat products, may help to relieve symptoms. Therapies such as TENS, acupuncture, vitamin B1 and magnesium help some women with painful periods. There is currently insufficient evidence to show whether such therapies are effective at relieving the pain associated with endometriosis.
Is there anything else I should know?
• Taking the combined oral contraceptive (COC) pill or contraceptive patch treats the symptoms of endometriosis.• If you become pregnant, endometriosis is unlikely to put your pregnancy at risk.• Some women find that recreational exercise improves their wellbeing, which may help to improve some symptoms of endometriosis (for further information see• No treatment is guaranteed to work all the time for everyone.• Support groups are run locally for women with endometriosis.• Internet forums may be the first place many women turn to for support. The quality of information can be variable. Surgery for stress incontinence: information for you
• https://www.nice.org.uk/guidance/ng123/resources/patient-decision-aid-pdf-6725286110• https://www.rcog.org.uk/en/patients/menopause/incontinence-and-bladder-problems/
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Key points
• When you have stress incontinence, you accidentally leak urine during normal everyday activities (for instance if you cough, sneeze, laugh, exercise or change position).• What you do about stress incontinence will depend on how far it affects you and what you feel you can cope with. Physiotherapy and/or practical advice from a continence nurse specialist on managing your daily life may help.• Not everyone with stress incontinence needs surgery, but if your problems persist, your doctor may suggest it.• Surgery for stress incontinence aims to give you more control over your bladder. It cannot always cure the problem completely.• There are a number of possible operations; what is suitable for you will depend on your circumstances.• Surgical procedures for stress incontinence are not usually suitable if you still plan to have children or think you might want to in the future.
About this information
This information is intended to help women who have stress incontinence and are considering whether to have surgical treatment for it. It is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guidelineIt tells you:
• what stress incontinence is;• the recommendations the guideline makes for the UK about the most effective surgical treatments for stress incontinence.
It aims to help you and your health care team to make the best decisions about your care. It is not meant to replace advice from a doctor, nurse or continence adviser about your own situation.It does not look at treatments for stress incontinence that do not involve surgery.
• Some of the recommendations here may not apply to you; this could be because of some other illness you have, your general health, your wishes, or some or all of these things. If you think the treatment or care you get does not match what we describe here, talk about it with your doctor or with someone else in your health care team.
What is stress incontinence?
The muscles of the pelvic floor (see diagram below) support the bladder and usually help keep it closed or open as necessary. Stress incontinence usually happens when these muscles become weak. So when there is sudden extra pressure (‘stress') on your bladder, it cannot stay closed as it should and some urine leaks out. This leakage happens during normal everyday activities, and most often when you cough, sneeze, laugh exercise or change position. Whether you leak a small or large amount of urine, stress incontinence can be embarrassing and distressing.
Stress incontinence can be triggered by pregnancy, childbirth or the menopause. If the problem develops while you are pregnant or after you have a baby, it usually improves with time for most women. Sometimes it happens again later on and a few women may need to consider surgery. Side view of a woman's bladder, pelvic floor muscles and nearby organs is found at the end
Do I need an operation?
Many treatments for stress incontinence do not involve surgery. Not everyone with stress incontinence needs an operation. Whether you choose to have surgery will depend on how far stress incontinence affects your daily life and what you feel you can cope with. You may want to consider surgical options if other things (such as exercises to help strengthen the muscles in the pelvic floor) have not helped.Surgical procedures for stress incontinence are not usually suitable if you still plan to have children or think you might want to in the future.Your doctor should already have asked you about the problems you have been having. You may have had a urine test to check for infection. You may also have had special bladder tests (known as urodynamics).
You should already have had advice from your doctor or a continence nurse specialist about:
• adjusting your daily routines to help you cope better• how you can help yourself by losing weight if you are overweight• managing a chronic cough if you have one• special physiotherapy exercises to make your pelvic floor muscles stronger and improve control of your bladder• giving up smoking
These things will also help to improve the results of surgery if you have it.
If you have seen no improvement after doing pelvic floor exercises, your doctors may suggest you consider surgery. If you are offered the choice of surgery, it is up to you to decide if and when you should have it.
What operation will I be offered?
Surgical procedures for stress incontinence aim to improve support for the muscles around the bladder entrance, in order to help the outlet (known as the urethra) to stay closed when it should and prevent it leaking.
No operation can be guaranteed to cure your stress incontinence, but most offer a good chance of making an improvement. The benefits of some last longer than others. The risk of developing extra problems (known as complications) also varies depending on the procedure.You can find more information about the main operations used to help stress incontinence in the tables on the following pages. They are:
• Burch colposuspension• Vaginal tapesYou can also find out about procedures that are used less often. They are:• Bulking agents• Sling procedures• Artificial sphincters• Anterior vaginal repair.
Your surgeon may offer you a choice of one or two methods, depending on your circumstances and his or her own expertise. He or she will take into account such things as your general health, age, weight, and previous operations and should explain the reasons for recommending a particular operation to you. Some operations are very specialised and are only offered in special centres.
If your surgeon is not able to offer the operation that best meets your individual needs, you may be able to find another who can. You should discuss this with your GP.
With some operations, you may need to have a temporary catheter. This is a tube which is put into your urethra (the tube leading out of the bladder) or your lower abdomen, in order to empty your bladder when necessary. The length of time you need to spend in hospital after the operation will vary depending on the type of operation and how quickly you recover. What might happen if I don't have an operation?
Your problems may remain the same, or get worse, or improve over time. There is no sure way of predicting this.
Are there any alternatives?
There is often no need to rush into having surgery. Some people prefer not to have an operation and find ways of adapting. Your continence adviser can tell you more about this.New surgical techniques are being developed all the time. You should talk to your continence adviser and/or your consultant to find out if there is anything new that might be more suitable for you.
There is not yet enough evidence about a procedure called paravaginal repair to show how effective it is. More research is needed.
Women who have a prolapse, where part of the bladder pushes through the vaginal wall, may be offered a procedure known as anterior repair. The surgeon makes a cut inside the front of the vaginal wall, to remove the extra tissue from the prolapse and restore the muscle support. If you also have stress incontinence, however, sling procedures are more effective than this operation.
Some operations are no longer recommended:
• Marshall-Marchetti-Krantz (MMK) colposuspension used to be common but has been replaced by other methods.• Needle suspension has been replaced by safer, more effective procedures.Is there anything else I should know?• All operations carry some risks. Your doctors should discuss with you the risks of any operation they offer you.• No treatment can be guaranteed to work all the time for everyone.
Sources and acknowledgements
This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG)
An abnormal Pap smear result/Cervical screening: What this means for you
In December 2017, the Cervical Screening Test replaced the Pap test in Australia. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1
• When you have stress incontinence, you accidentally leak urine during normal everyday activities (for instance if you cough, sneeze, laugh, exercise or change position).• What you do about stress incontinence will depend on how far it affects you and what you feel you can cope with. Physiotherapy and/or practical advice from a continence nurse specialist on managing your daily life may help.• Not everyone with stress incontinence needs surgery, but if your problems persist, your doctor may suggest it.• Surgery for stress incontinence aims to give you more control over your bladder. It cannot always cure the problem completely.• There are a number of possible operations; what is suitable for you will depend on your circumstances.• Surgical procedures for stress incontinence are not usually suitable if you still plan to have children or think you might want to in the future.
About this information
This information is intended to help women who have stress incontinence and are considering whether to have surgical treatment for it. It is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guidelineIt tells you:
• what stress incontinence is;• the recommendations the guideline makes for the UK about the most effective surgical treatments for stress incontinence.
It aims to help you and your health care team to make the best decisions about your care. It is not meant to replace advice from a doctor, nurse or continence adviser about your own situation.It does not look at treatments for stress incontinence that do not involve surgery.
• Some of the recommendations here may not apply to you; this could be because of some other illness you have, your general health, your wishes, or some or all of these things. If you think the treatment or care you get does not match what we describe here, talk about it with your doctor or with someone else in your health care team.
What is stress incontinence?
The muscles of the pelvic floor (see diagram below) support the bladder and usually help keep it closed or open as necessary. Stress incontinence usually happens when these muscles become weak. So when there is sudden extra pressure (‘stress') on your bladder, it cannot stay closed as it should and some urine leaks out. This leakage happens during normal everyday activities, and most often when you cough, sneeze, laugh exercise or change position. Whether you leak a small or large amount of urine, stress incontinence can be embarrassing and distressing.
Stress incontinence can be triggered by pregnancy, childbirth or the menopause. If the problem develops while you are pregnant or after you have a baby, it usually improves with time for most women. Sometimes it happens again later on and a few women may need to consider surgery. Side view of a woman's bladder, pelvic floor muscles and nearby organs is found at the end
Do I need an operation?
Many treatments for stress incontinence do not involve surgery. Not everyone with stress incontinence needs an operation. Whether you choose to have surgery will depend on how far stress incontinence affects your daily life and what you feel you can cope with. You may want to consider surgical options if other things (such as exercises to help strengthen the muscles in the pelvic floor) have not helped.Surgical procedures for stress incontinence are not usually suitable if you still plan to have children or think you might want to in the future.Your doctor should already have asked you about the problems you have been having. You may have had a urine test to check for infection. You may also have had special bladder tests (known as urodynamics).
You should already have had advice from your doctor or a continence nurse specialist about:
• adjusting your daily routines to help you cope better• how you can help yourself by losing weight if you are overweight• managing a chronic cough if you have one• special physiotherapy exercises to make your pelvic floor muscles stronger and improve control of your bladder• giving up smoking
These things will also help to improve the results of surgery if you have it.
If you have seen no improvement after doing pelvic floor exercises, your doctors may suggest you consider surgery. If you are offered the choice of surgery, it is up to you to decide if and when you should have it.
What operation will I be offered?
Surgical procedures for stress incontinence aim to improve support for the muscles around the bladder entrance, in order to help the outlet (known as the urethra) to stay closed when it should and prevent it leaking.
No operation can be guaranteed to cure your stress incontinence, but most offer a good chance of making an improvement. The benefits of some last longer than others. The risk of developing extra problems (known as complications) also varies depending on the procedure.You can find more information about the main operations used to help stress incontinence in the tables on the following pages. They are:
• Burch colposuspension• Vaginal tapesYou can also find out about procedures that are used less often. They are:• Bulking agents• Sling procedures• Artificial sphincters• Anterior vaginal repair.
Your surgeon may offer you a choice of one or two methods, depending on your circumstances and his or her own expertise. He or she will take into account such things as your general health, age, weight, and previous operations and should explain the reasons for recommending a particular operation to you. Some operations are very specialised and are only offered in special centres.
If your surgeon is not able to offer the operation that best meets your individual needs, you may be able to find another who can. You should discuss this with your GP.
With some operations, you may need to have a temporary catheter. This is a tube which is put into your urethra (the tube leading out of the bladder) or your lower abdomen, in order to empty your bladder when necessary. The length of time you need to spend in hospital after the operation will vary depending on the type of operation and how quickly you recover. What might happen if I don't have an operation?
Your problems may remain the same, or get worse, or improve over time. There is no sure way of predicting this.
Are there any alternatives?
There is often no need to rush into having surgery. Some people prefer not to have an operation and find ways of adapting. Your continence adviser can tell you more about this.New surgical techniques are being developed all the time. You should talk to your continence adviser and/or your consultant to find out if there is anything new that might be more suitable for you.
There is not yet enough evidence about a procedure called paravaginal repair to show how effective it is. More research is needed.
Women who have a prolapse, where part of the bladder pushes through the vaginal wall, may be offered a procedure known as anterior repair. The surgeon makes a cut inside the front of the vaginal wall, to remove the extra tissue from the prolapse and restore the muscle support. If you also have stress incontinence, however, sling procedures are more effective than this operation.
Some operations are no longer recommended:
• Marshall-Marchetti-Krantz (MMK) colposuspension used to be common but has been replaced by other methods.• Needle suspension has been replaced by safer, more effective procedures.Is there anything else I should know?• All operations carry some risks. Your doctors should discuss with you the risks of any operation they offer you.• No treatment can be guaranteed to work all the time for everyone.
Sources and acknowledgements
This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG)
An abnormal Pap smear result/Cervical screening: What this means for you
In December 2017, the Cervical Screening Test replaced the Pap test in Australia. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1