Symptoms
We see women and gender diverse people with a wide range of symptoms, often related to changes in the life cycle or menstrual cycles. Some of the more common symptoms we see are listed here:
Bleeding
There are a range of causes for bleeding that is heavy enough to be affecting quality of life, or is not following a normal cycle pattern. The problem is generally either a structural cause (something we can see either with a pelvic ultrasound or a surgical procedure) or a functional cause (related to hormones, problems with how the blood is clotting, or how body systems are interacting with each other).
Polyps - Polyps are growths that can form in many places in the body including the endometrium (lining of the uterus) and cervix. These kinds of polyps are usually benign (not cancer), and can cause bleeding between periods or after sex, and can make periods heavier. Polyps can usually be found and removed with a hysteroscopy which is procedure involving a camera being placed inside the uterus
Adenomyosis - The lining of the uterus (endometrium) bleeds with periods, and is normally a completely separate layer from the muscle on the outer part of the uterus (myometrium). When these layers start to blend together, there is bleeding tissue within the muscle that can cause heavy and painful periods. This is called adenomyosis, and is closely related to endometriosis. Adenomyosis can often be diagnosed with a pelvic ultrasound. Adenomyosis is a benign (not cancer) condition, and treatment is to improve pain and/or bleeding. Treatment can involve medications or surgery.
Fibroids - Fibroids are very common benign (not cancer) growths coming from the muscle of the uterus (myometrium). Fibroids can grow on the inside or outside of the uterus, or within the muscle of the uterus. They can range from less than 1cm greater than 8cm. Some fibroids do not cause any problems, others can contribute to heavy bleeding (especially if they are inside the cavity of the uterus - submucosal), cause pain or pressure, and occasionally affect the bowels or bladder, or fertility. Not all fibroids need treatment, but when treatment is needed, this generally means surgery to remove the uterus (hysterectomy), or in some cases (such as when further pregnancies are wanted) remove just the fibroids (myomectomy).
Cancer and Hyperplasia - The lining of the uterus (endometrium) can start to grow in an abnormal way, called hyperplasia. This is a condition that needs treatment, as it can lead to endometrial cancer if not treated. The biggest risk factors for hyperplasia are being overweight, and having never been pregnant. The treatment depends on how abnormal the cells are, and whether you want to become pregnant in the future. Treatment can involve hormonal medications or surgery to remove the uterus (hysterectomy). Endometrial cancer is usually cured with a hysterectomy, but cases are always referred to the gynaecology oncology service at Wellington Hospital to check whether any further treatments or investigations are recommended. Sometimes the gynaecology oncology team will recommend that they take over care.
Bleeding Disorders - The blood needs to be able to clot to stop any active bleeding. There are lots of conditions that affect how the blood is able to clot, and all of these can make periods heavier or cause abnormal bleeding. The most common conditions are von Willebrand's Disease and haemophilia. Treatment usually includes medications, and sometimes a referral to a haematologist (blood specialist).
Ovulation Problems - Anything that affects the menstrual cycle can cause abnormal bleeding. The menstrual cycle is regulated by part of the brain called the pituitary gland, which signals to the ovaries when to release specific hormones and when to ovulate (release eggs). There are lots of ways this cycle can be interrupted which can lead to abnormal bleeding patterns. Some common causes include Polycystic Ovarian Syndrome (PCOS), changes due to stress, or intense sport (Relative Energy Deficiency in Sport - RED-S); there are also many other causes.
Pain
Pelvic pain is complex and can have huge impacts on quality of life. Pain can come on suddenly, or be persistent over a long period of time. Finding the cause of pelvic pain is often not simple, and often there is more than one factor contributing to pain. Finding the cause and getting pain under control might involve multiple tests, healthcare professionals and treatments.
Endometriosis - Our best guess is that about 1 in 10 women have endometriosis. This is where tissue similar to the lining of the uterus (endometrium) is growing somewhere outside of the uterus. This tissue can grow on the surface of structures, or start to create deeper nodules. It's most commonly seen on the ovaries, the sidewalls of the pelvis, the surface of the uterus and the ligaments attaching to the uterus. It can also involve the bladder, the bowels, the fallopian tubes, the diaphragm and sometimes other places. The most common reason for people with endometriosis to see a doctor is pain related to their cycles. There are multiple other symptoms that can be caused by endometriosis. This can depend on the extent and location of the abnormal areas, and symptoms can include difficulty falling pregnant, painful bowel motions, pain during or after sex and a range of other symptoms. Ultrasound has become much better at diagnosing endometriosis over the last few years, and can now fairly reliably diagnose severe endometriosis (although this is very dependent on the skill of the sonographer performing the scan). Unfortunately a normal ultrasound does not rule out endometriosis, especially milder forms. This means surgery is often the only way to confirm the diagnosis. Treatment depends on the individual, and usually involves either hormonal medications to improve symptoms, or surgery to remove all of the endometriosis. If hormonal medications treat the symptoms well, surgery may not be necessary. We practice in line with the ESHRE and RANZCOG endometriosis guidelines. A useful source of information is Endometriosis New Zealand.
Ovarian Cysts - Ovarian cysts are common, and are usually benign (not cancer) but can be cancer or borderline (not quite cancer, but not quite benign). Unlike other parts of the body we can't take biopsies of the ovary, as this can spread ovarian cancer. This means we need to work out how likely a cyst is to be cancer using imaging tests (pelvic ultrasound and sometimes CT or MRI) and blood tests. Tumour markers are blood tests that go up with certain types of cancer. The most useful tumour marker for ovarian cancer is CA-125. There are several other tumour markers that are used to assess the risk of cancer depending on the age of the patient and the ultrasound findings. There are multiple different types of benign and cancerous cysts. Ultrasound gives us a good insight into the type of cyst, but is not perfect.
A cyst that is very likely to be benign (not cancer) often requires surgery, and can usually be removed using keyhole surgery (laparoscopy). The cyst is often able to be removed without removing the ovary, but this depends on the size and type of the cyst, the age of the patient and what the patient prefers.
A cyst that has a higher risk of being cancer is referred to the gynaecology oncology service in Wellington Hospital. The gynaecology oncology team may recommend taking over care, or may recommend surgery to remove the ovary, and take biopsies of other structures in the abdomen. This surgery is usually open surgery (an incision on the abdomen similar to a caesarean section, or in the midline from the pubic bone up to the belly button or occasionally higher).
Adenomyosis - The lining of the uterus (endometrium) bleeds with periods, and is normally a completely separate layer from the muscle on the outer part of the uterus (myometrium). When these layers start to blend together, there is bleeding tissue within the muscle that can cause heavy and painful periods. This is called adenomyosis, and is closely related to endometriosis. Adenomyosis can often be diagnosed with a pelvic ultrasound. Adenomyosis is a benign (not cancer) condition, and treatment is to improve pain and/or bleeding. Treatment can involve medications or surgery.
Pelvic Floor - The muscles of the pelvic floor can contribute to pelvic pain. Treating this can be a difficult process, and often involves a skilled pelvic physiotherapist. Pain arising from the muscles in the pelvic floor can be very different between people, but is often worse with sex or sometimes even with anticipation of sex. This type of pain often develops secondary to other causes of pain like endometriosis. Sometimes Botox injections into these muscles helps as an adjunct to physiotherapy.
Persistent Pelvic Pain - All of the above factors can contribute to pelvic pain, as well as many other causes including the bowels (irritable bowel syndrome), the bladder (painful bladder syndrome), the nerves (neuropathic pain). All of these causes, and sometimes other triggers, can change how pain systems function in the body.
Pain system hypersensitivity (which has lots of other names including nociplastic pain and central sensitisation) can be a complex process in the body that results in the experience of pain even without triggers to activate the pain system. The pain system starts at pain receptors all over the body (nociceptors), that send signals to the spinal cord. Within the spinal cord there is a complex set of processing of these signals that is also influenced by other signals from the body. The spinal cord then sends these processed signals to the brain. Anything that causes pain for a long period of time affects how the spinal cord processes pain signals (this is what "central sensitisation" really refers to). Many different parts of the brain interact to process these signals in an even more complex way. Changes to any part of this system including the pain receptors, the nerves, the spinal cord and the brain can affect the experience of pain.
Persistent pelvic pain due to Pain system hypersensitivity can be extremely debilitating; getting control of it can involve multiple healthcare professionals including a gynaecologist, pelvic physiotherapist, pain specialist and others. For more information see the Pelvic Pain Foundation of Australia.
Cervical Screening Results
The cervical screening programme in New Zealand recommends that all people with a cervix aged 25-69 are screened five yearly for high risk strains of the Human Papilloma Virus (HrHPV), which causes almost all cervical cancer. This is a screening test, which is designed to screen normal healthy people who don't have any symptoms. People experiencing symptoms (such as bleeding after having sex) or who have abnormal screening results should be referred for colposcopy.
A colposcope is a strong magnifying glass that allows a detailed check of the cervix. The colposcope does not actually touch the patient, it sits about 20-30cm away. The process involves sitting on a specially designed chair that raises into the air and separates the legs apart. If there are any abnormal areas on the cervix at colposcopy, a small biopsy may need to be taken from the cervix.
Vulval Skin Changes
Any condition that occurs on the skin can also occur on the vulva, as well as a set of conditions that only affect this area. These can cause itchiness, discharge, lumps and bumps, ulcers, rashes and other symptoms. Conditions like dermatitis and psoriasis often occur in other places in the body as well as the vulva, and the treatment may involve identifying any triggers, and using steroid creams.
A common condition called lichen sclerosus is very common after menopause, and also occasionally affects women before menopause. Lichen sclerosus causes itchiness and irritation and often thickened white areas around the vulva and anus. Longstanding lichen sclerosus often leads to changes or flattening of the folds of skin around the clitoris and the labia minora (the inner skin folds of the vulva). We recommend reading the Wellington Hospital patient information sheet.
Skin cancers can arise in the skin on the vulva. Lichen sclerosus is a risk factor for this. Any ulcers, lumps or other changing or unusual areas on the vulval should be checked. Sometimes a small biopsy may need to be taken to find out whether an area is cancer or not.
Menopause
There is a huge variation in the experience of menopause. The average age of menopause is 51, but this can vary greatly (most often between 45-55). Menopause can occur naturally, or due to surgery, chemotherapy, radiation or other medications. The amount of oestrogen in the body becomes much lower, and this is the key driver in a range of changes in the body. Hot flushes and night sweats are common, and can range from mild to very debilitating. There can be effects on mood, cognition (ability to think straight), sleep and libido (sex drive). Low oestrogen levels can also cause physical changes to the skin on the vulva, and cause dryness, discomfort and increase the chance of urinary tract infections.
Menopausal hormone therapy (MHT, previously known as HRT - Hormone replacement therapy) is one option that can help with many of these symptoms. While MHT is the most effective treatment for, there are also a range of options that don't involve medications as well as non-hormonal medications that can help with specific symptoms. The goal of treatment is to improve quality of life.
Fertility
A fertility workup should be considered for couples are trying to fall pregnant unsuccessfully for more than 12 months (or more than 6 months if the woman is aged 35 or older); or if there are other concerns like three or more miscarriages. All IVF treatment in Wellington is done at Fertility Associates, and needs the supervision of a Fertility Specialist. A GP or specialist can refer directly to Fertility Associates, and this visit may be publicly funded in some cases (outlined on their website here). Please check with your insurance provider as to whether your consultation will be covered, as some policies exclude infertility consultations.
A basic fertility workup can be arranged by a GP, but in some cases will involve a additional investigations such as hysteroscopy (camera inside the uterus) or laparoscopy (keyhole surgery to look for endometriosis or check the fallopian tubes). We perform these procedures, and can provide a general fertility workup and advice; but we are not a fertility specialist service, and may need to refer you to Fertility Associates for further advice or treatment.
Prolapse
The pelvic floor is a set of muscles shaped like a bowel that sits within the bones that form the pelvis. There are small gaps in these muscles to allow the bowels and the bladder to empty. In women the vagina forms a third gap in this muscle. During childbirth the baby passes through this gap which causes a big stretch on these muscles. Sometimes these muscles are also torn or damaged in the process. This can lead to parts of the pelvic floor muscles being less able to hold the contents of the pelvis in place. The uterus, rectum and/or bladder can start to push down onto the vagina. This can cause an uncomfortable or sometimes painful bulging sensation, and can at times affect bowel or bladder function, leading to either incontinence (loss of control) or difficulty passing bowel motions. We recommend reading the IUGA patient information sheet.
Treatment for prolapse can involve pelvic floor training, pessaries or surgery. Lifestyle changes like being a healthy weight and avoiding heavy lifting can often help. Pelvic physiotherapists can be extremely helpful in improving how the pelvic floor muscles work, using a range of techniques including Kegel's exercises. Sometimes a small device called a pessary can be placed inside the vagina to reduce the prolapse. There are a range of different pessary types, shapes and sizes. The size and type of the prolapse and the symptoms that it's causing will determine which pessary is right. Some women prefer to have a pessary in all the time, while others prefer to take the pessary in and out and only use for for particular situations like exercising. Surgery is also an option for prolapse, and can involve strengthening the skin and tissue between the vagina and either the rectum or bladder, or stopping the uterus from coming down either by performing a hysterectomy (removing the uterus), or attaching the top of the vagina to a ligament in the back of the pelvis (sacrospinous fixation). In the past surgical mesh was used for this type of surgery. Unfortunately many women suffered as a result of complications of mesh, and as a result no mesh is used for prolapse surgery in New Zealand outside of specific circumstances. We do not use any surgical mesh for any surgery.
Note that all incontinence surgery and any complex prolapse surgery (such as when there has been previous prolapse surgery, or permanent sutures or mesh procedures are being considered) should be referred to a urogynaecology subspecialist, or a gynaecology with a special interest and credentialling for this type of surgery. These type of surgeries carry higher risk. If we feel that this would be better we can discuss options and refer you to an appropriate specialist in the region.