Pelvic organ prolapse is a condition in which the pelvic floor muscles and support structures become weak, allowing the bladder, bowel and uterus to bulge into the vagina. Prolapse does not always cause symptoms. If symptoms are present, patients may experience pelvic pressure, pain or vaginal bulge. Other symptoms include urinary frequency, urgency or difficulties voiding. Some patients have difficulties passing bowel movements. Prolapse can be also be associated with urinary incontinence.
Prolapse is diagnosed with a pelvic exam. Treatment is not required unless the symptoms are bothersome. Treatment options include pelvic floor physiotherapy (or Kegel exercises), a pessary or surgery. A pessary is a silicone ring that fits in the vagina to hold the tissues back in place. There are many different shapes and sizes. Your gynecologist can fit you with one at your appointment. Pessaries are not covered by MSP. We can provide you with one for $65. Other lifestyle measures that are important to prevent prolapse from progressing include weight loss and avoiding constipation, heavy lifting or chronic cough.
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Urinary incontinence (leaking of urine) is common. Not all patients seek treatment for this condition, and this often depends on the severity of leaking and the impact that it has on a particular person’s quality of life. Risk factors for incontinence include, having female anatomy, aging, previous pregnancies and childbirth, obesity, and family history.
The major categories of urinary incontinence include stress incontinence, urgency incontinence, mixed incontinence, and overflow incontinence. Urgency incontinence can often be found in conjunction with a condition called overactive bladder. Stress incontinence occurs when the pressure placed on the bladder is greater than what the mechanisms that are in place to hold urine in can withstand. Patients with overactive bladder often describe an urgent and frequent need to urinate and sometimes an inability to make it to a toilet in time before leaking occurs.
Sometimes urinary incontinence is evaluated and treated by specialists in gynecology or by specialists in urology. When you see a gynecologist for evaluation of urinary incontinence, it will always start with a detailed history and then a physical exam to try to determine the type and severity of incontinence. We want to make sure that you don’t have a urinary tract infection and will send a urine sample away for testing. We often want to make sure that your bladder can empty completely. Occasionally more invasive testing is needed by way of a procedure called urodynamic testing. When urinary incontinence is more complex or difficult to treat, some women will require further evaluation and/or treatment by a urologist or urogynecologist (a sub-specialist in urogenital issues).
The foundation of treatment of urinary incontinence includes education, avoidance of bladder irritants in your diet, keeping a bladder diary to characterize the leaking episodes and a careful evaluation of fluid intake. For patients who are overweight, even small to moderate weight loss can improve symptoms. Often a specialized pelvic floor physiotherapist can help you to learn more about your pelvic floor and teach you targeted exercises to improve your symptoms. Depending on the type of incontinence you have, further treatment including medications, use of a vaginal insert called a pessary and surgery may be options for you. These options will be discussed at your consultation.
If you have been referred to us and are waiting for an appointment or if you are interested in learning more, this website is an excellent place to start:
www.yourpelvicfloor.org This is the website of the International Urogynecology Association. I suggest looking under “ Resources”🡪 “Download Leaflets” and good topics to start reading about are: Bladder Diary, Bladder Training, Non-Surgical Approaches to Managing Bladder Problems, Overactive Bladder, Pelvic Floor Exercises and Stress Urinary Incontinence.
Lichen sclerosus is a common vulvar skin disorder that affects the anogenital region. Symptoms include vulvar itching, discomfort or pain. It can also contribute to pain with sexual activity. The skin appears thin, white and wrinkled. Other skin surfaces can be affected such as the thighs, breasts, wrists, shoulders, neck and inside of the mouth. With advanced disease there can be scarring and a change in the normal appearance of the vulva. The cause is unknown. It is diagnosed on physical exam and skin biopsy. Patients with lichen sclerosus are at slightly increased risk for developing vulvar cancer. A yearly vulvar exam is recommended once a diagnosis of lichen sclerosus is made. Treatment includes avoidance of vulvar irritants and regular application of a steroid ointment to the affected area. The goal of treatment is to relieve the symptoms, control the disease and prevent progression.
Menopause is a normal physiologic process associated with aging, that is defined as 12 months of no menstrual periods. There is no blood test to diagnose menopause as it is a time of hormonal change, and on any given day hormone levels can vary significantly. The average age of menopause in Canada is age 51, however some people will go through this transition earlier, and some later.
Peri-menopause or the menopausal transition is defined as the period leading up to menopause when people can experience many changes in their body. This lasts on average 4 years but can last much longer. These include vasomotor symptoms, commonly termed hot flashes or night sweats, changes in menstrual bleeding patterns when periods can become more frequent, less frequent, heavier and more painful, mood changes, sleep disturbance, vaginal dryness and changes in sexual function.
Up to 80% of patients experience vasomotor symptoms, ranging from mild to severely debilitating. The mainstay of treatment is hormone therapy with estrogen, with or without progesterone. There are other non-hormonal treatments, and you can discuss with your doctor a treatment that is right for you.
This is also a time when bone density, lipids (cholesterol) and weight starts to change. It is a time when exercise and healthy diet remain very important to overall health and managing these changes. Calcium and vitamin D supplementation are also recommended.
Some people experience 12 months of no menstrual periods prior to age 40, and this is not normal. It is important to discuss this with your doctor if this is happening to you.
Endometrial cancer is the most common gynecological cancer. It arises from the inner lining of the uterus and most often occurs in postmenopausal patients. Some risk factors include early onset of menstruation (<12 years of age), late menopause, infrequent menstruation, obesity, never having children, unopposed estrogen. It usually presents with abnormal vaginal bleeding (heavy menstrual bleeding or intermenstrual bleeding) or bleeding after menopause. An office endometrial biopsy is required to assess the inner lining of the uterus and make a diagnosis. If cancer is detected, surgery will be done to remove the uterus, fallopian tubes and ovaries, called a hysterectomy and bilateral salpingo-oophorectomy. This will determine how far the cancer has spread. The surgery can be done through an incision on the lower abdomen or laparoscopically through multiple smaller incisions. Sometimes chemotherapy or radiation are used as adjunct treatments. The type of cancer cells and the extent of the disease will determine whether additional treatment is required after surgery.
Cervical cancer occurs when normal cervical cells change into abnormal cells and grow out of control. The main two types of cervical cancer are squamous cell carcinoma and adenocarcinoma. The most important risk factor for cervical cancer is infection with the human papilloma virus (HPV). About 80% of people become exposed to HPV virus during their lifetime through direct skin to skin contact and through sexual activity. However, usually the body’s immune system can get rid of the virus before it causes precancerous changes to the cervix. The HPV vaccine is recommended between the age of 9 and 45 years to prevent acquiring HPV that can cause genital warts or precancerous changes to the cervix. Other risk factors for cervical cancer include multiple partners, smoking and having a medical condition or taking medication that weakens the immune system. The Pap smear is a screening test for cervical cancer and abnormalities can be detected at an early stage so that treatment can be given before it develops into cervical cancer.
There are usually no symptoms during early stage cervical cancer. However, at a more advanced stage, it can present with abnormal bleeding such as between periods, after sexual activity or bleeding in menopause. If cervical cancer is diagnosed, treatment will depend on the spread of the cancer, age of the patient, desire to maintain fertility and other co-existing health conditions. The treatment is either a hysterectomy or chemotherapy and radiation.
Ovarian cancer is the second most common gynecological cancer and usually occurs between the ages of 50 and 65. The lifetime risk of developing ovarian cancer is about 1.4%. The most common type is epithelial ovarian cancer. Risk factors include never having been pregnant, starting menstruation at an early age (before age 12), going through menopause at an older age (after age 52) and a family history. Unfortunately, patients often do not have symptoms with early stage disease and therefore it is not diagnosed until the cancer is advanced. Symptoms include pelvic or abdominal discomfort, bloating, decreased appetite, a feeling of fullness after eating only a small amount of food and urinary symptoms. Investigations to diagnose ovarian cancer include imaging such as ultrasound, CT scan or MRI. Blood work will also be done, including tumor markers. The most common tumor marker that will be assessed is CA 125. Treatment consists of removing the uterus, fallopian tubes, ovaries and as much tumor as possible. Often chemotherapy will also be given either before or after surgery. Treatment is more successful in younger patients, when the cancer is diagnosed at an early stage and when most of the tumor was removed during the initial surgery.
Vulvar cancer is a less common gynecological malignancy. It often affects patients in their late 60s and is usually diagnosed at an early stage. The most common type is a squamous cell cancer associated with HPV infection. However it can also develop from chronic inflammation or an autoimmune process. Lichen sclerosis, a common vulvar skin disorder, is a risk factor for developing vulvar cancer. Other risk factors include precancer changes on the cervix and vulva, a history of cervical cancer, smoking and immunocompromise. Symptoms can include burning, itching, bleeding, pain, white patches, a lump or ulcer. The vulvar lesion can vary in appearance. Therefore, a biopsy is required for diagnosis. Treatment of vulvar cancer involves surgical removal of the affected area and surrounding tissue, called a vulvectomy. Sometimes this is combined with radiation. If the disease is locally advanced and cannot be surgically removed, then chemoradiation is the treatment of choice.
The Pap smear is a screening test for cervical cancer. The current BC Cancer Agency guidelines recommend Pap smears starting at the age of 25 and every 3 years thereafter until the age of 69. If a Pap smear is abnormal, the recommendation will be either to have a repeat test in 6 months or proceed with a colposcopy. A colposcopy is a magnified examination of the cervix using a colposcope where directed biopsies can be taken from areas of abnormality. If precancer or cancer is diagnosed on biopsy, a LEEP cone biopsy is usually the next step. During the LEEP, the area of abnormality is removed under local anesthetic. It is usually done on an outpatient basis. If precancer is detected on the pathology report from the LEEP, there will be ongoing surveillance through the colposcopy clinic to monitor for any recurrence. However, if cervical cancer is diagnosed on the LEEP specimen, then either a hysterectomy and/or radiation with possible chemotherapy will be recommended depending on the extent of the cancer.
Contraception refers to methods used to prevent pregnancy either temporarily or permanently. For individuals who desire pregnancy, contraception can play a role in family planning and pregnancy timing and spacing.
There are many forms of contraception with varying efficacies. These include natural family planning methods such as cycle tracking and avoiding intercourse during the fertile window. Barrier methods such as condoms and diaphragms are available without a prescription. Hormonal methods include the oral contraceptive pill, transdermal patch and contraceptive ring. Long acting reversible contraceptives that are the most efficacious reversible methods, include injectable progestin, the progestin intrauterine contraceptive device (IUD), the non-hormonal copper IUD, and the contraceptive implant. Many hormonal contraceptives are used to treat other conditions, such as heavy or irregular periods and pelvic pain.
Some people experience side effects from hormonal contraception, however there are many types of hormonal contraceptives and people often will not experience the same side effects with each type. Some people have medical conditions that preclude them from using certain hormonal contraceptives.
There are two types of permanent contraceptives. Vasectomy is a surgical procedure performed on the testicles. This can often be performed in the office setting by a urologist under local anaesthetic. Laparoscopic tubal occlusion (tubal ligation), which involves removing a segment of each fallopian tube, or laparoscopic bilateral salpingectomy, which is removal of the fallopian tubes, are other permanent options. These day procedures are performed in the operating room under general anaesthetic and do not require a hospital admission.
Often your family doctor or nurse practitioner can work with you to find a contraceptive that is right for you. If you are interested in laparoscopic tubal occlusion or bilateral salpingectomy, then you will be referred to a gynecologist to discuss this further.
For more information, please visit this website:
Abnormal uterine bleeding is a vaginal bleeding pattern that is outside of what is considered normal menstrual bleeding. A normal menstrual cycle in a reproductive age person who is not pregnant, consists of 3-8 days of bleeding every 21-35 days, with a total of 30-50 mL (2-3 tablespoons) of blood loss or less over a single period. Any recurrent variation from this pattern can be considered abnormal uterine bleeding. This includes menstrual bleeding that is heavier, more prolonged, irregular, occurring on days between periods, bleeding that occurs after intercourse, and bleeding after menopause. Another important consideration is if your vaginal bleeding is disruptive to your life.
Many different things can cause abnormal uterine bleeding. One of the most common causes is anovulatory bleeding from perimenopause or polycystic ovarian syndrome, when a person is not getting a period monthly. Other common causes include adenomyosis, fibroids and endometrial polyps. Less commonly, bleeding disorders, infection or pre-cancer or cancer of the cervix or endometrium can be a cause. Depending on your symptoms and your age, your family doctor/nurse practitioner or your gynecologist may recommend some investigations such as blood work, vaginal swabs, a pelvic ultrasound or an endometrial biopsy. Not all patients require these tests prior to treatment.
There are many effective treatment options for abnormal uterine bleeding. These range from non-hormonal and hormonal medications, to the hormonal IUD as well as surgery. Your doctor will discuss these options with you and find a management strategy that works for you.
Infertility is diagnosed when a patient is unable to get pregnant after 6-12 months of trying with regular and appropriately timed intercourse. There are many different reasons that this may occur. Your doctor will evaluate for potential causes with a physical exam, blood work and imaging such as a pelvic ultrasound and hysterosalpingogram (HSG). If you have a male partner, he may need to provide a semen sample for semen analysis.
Depending on the cause of your infertility, there are different treatment options including medications to help you ovulate. Occasionally, surgery is required. More advanced fertility treatments may be offered such as intrauterine insemination or in vitro fertilization. Advanced fertility treatments are usually managed by a fertility clinic that we may recommend further referral to.
You can optimize your chance of pregnancy by maintaining a healthy weight. If you have regular 28 day cycles, you should have intercourse every 1-2 days from day 9-15 of your cycle (day 1 is the first day of menses). The highest chance of conceiving is when intercourse occurs the day before or the day of ovulation. In a 28 day menstrual cycle, ovulation occurs on day 14. You can also purchase an ovulation predictor kit to help plan the optimal time for intercourse. It is helpful to prepare for a pregnancy by quitting smoking, avoiding alcohol and drugs, including cannabis, and taking a prenatal vitamin.
During the reproductive years, patients may experience painful menstrual periods. This is a common problem and there are multiple possible causes. Primary dysmenorrhea is the most common and is caused by the uterus cramping and causing pain during menstruation. Underlying issues such as fibroids, adenomyosis and endometriosis are other common causes for painful periods. These conditions may also contribute to pain or discomfort at other times in the menstrual cycle as well. When your doctor sees a patient with painful periods, they search for any identifiable underlying causes that could be contributing. The mainstay of treatment for painful periods due to most causes is with oral pain medications such as non-steroidal anti-inflammatories (ex. Ibuprofen) and through use of hormonal medications such as combined oral contraceptives (the birth control pill), progestin only medications, and hormone containing- intrauterine devices. While these treatments are effective for many patients, some will require surgery that can range from a diagnostic laparoscopy to a hysterectomy.
Endometriosis is common and varies widely on a case by case basis. Endometriosis is the presence of endometrial (uterine lining) tissue found outside the uterus, where it shouldn’t be. It is non-cancerous. While some patients with endometriosis may not be affected, others can present with painful periods, pelvic pain, painful sex, painful bowel movements and sometimes infertility. Endometriosis can often be diagnosed by your physician by history and physical exam alone. Surgery is not required before starting treatment for endometriosis. Surgery is appropriate for patients who are suspected to have endometriosis and who have failed multiple medical treatments and for those patients who are struggling to get pregnant, where it is thought endometriosis may be playing a role in their infertility. A diagnostic laparoscopy is used for diagnosis and if endometriosis is found, it can often be treated (removed or excised) at the same time. Patients with very severe endometriosis may have to be seen by specialists in minimally invasive surgery.
Chronic pelvic pain is pain in the pelvis that has persisted for more than 6 months and is present throughout the menstrual cycle (not just with periods). Chronic pain can have an impact on a patient’s ability to function in multiple domains of life and their quality of life overall. Almost always, there is not one specific cause, but several underlying issues that are contributing. As there is usually not one cause, there is also often not one answer. Chronic pain is complex and involves multiple body systems often including the musculoskeletal system and peripheral and central nervous systems. It can be associated with other conditions like irritable bowel syndrome, interstitial cystitis, pelvic floor dysfunction and fibromyalgia. Therefore, the approach to treating chronic pain is multidisciplinary and often requires multiple visits. The goal in treating chronic pelvic pain is to identify and treat any underlying causes where possible and to improve a patient’s pain overall and improve their quality of life.
These website provide additional information and resources for painful periods and pelvic pain:
Polycystic ovarian syndrome (PCOS) is a condition that causes irregular periods due to a hormonal imbalance leading to irregular ovulation. It can also be associated with acne and increased hair growth on the face, abdomen and inner thighs. It can be associated with obesity and difficulties getting pregnant. Other sequelae include endometrial hyperplasia (pre-cancer) or cancer, diabetes, high cholesterol and high blood pressure. The cause of PCOS is unknown.
PCOS is diagnosed with history and physical exam. You may require other investigations such as and endometrial biopsy, blood work and a pelvic ultrasound.
Treatment of PCOS is important to prevent endometrial hyperplasia or cancer. Treatment is aimed at regulating your menstrual cycles. This is achieved through a combination of weight loss for patients with associated obesity and with medication. Even modest weight loss of 5% body weight can promote regular ovulatory cycles. First line medications include the birth control pill (combined oral contaceptives) or an IUD. The birth control pill has secondary benefits of treating acne and irregular hair growth. If you would like to become pregnant, you may need medications to help with ovulation.
Willow Obstetrics and Gynecology would like to acknowledge that we are situated on the traditional territory of the Lheidli T’enneh.