What is post-menopausal bleeding? When the monthly periods stop for 12 months we call it menopause.  Any bleeding that happens after that is called post-menopausal bleeding.  Is it normal to have bleeding after menopause? It is never normal to have bleeding after menopause. Even if it is spotting, or slight smearing of blood on pad or happened only once or no pain it is still not normal and you should not ignore.  Is it cancer?  All women who have post-menopausal bleeding will not have cancer.  Only less than 10% women might have cancer. Rest of 90% might have simple reasons for bleeding.  What can be the reasons for the post-menopausal bleeding? Most common reason will be dryness of vagina also known as atrophy.  Other reasons might include small growths or polyps, infection of cervix or vagina, or use of hormone replacement pills. Less commonly there can be cancer of uterus or cervix or vagina.  What should I do when I notice post-menopausal bleeding?  Whenever you notice post-menopausal bleeding make an appointment with your doctor as soon as possible instead of postponing or observing for repetition.  What will happen at doctor’s visit?  When you visit the doctor will complaints of post-menopausal bleeding the doctor will take history of all your medical problems and check you which might involve internal check. If you are due for Pap smear or never had that done before Pap smear will be done which is twisting of soft brush at cervix – that is mouth of the uterus.  You will be advised ultrasound scan to check for any growths inside the uterus or abnormal thickness of uterine lining and also to rule out ovarian cysts.  You will be advised to have a biopsy of the lining of the uterus if it is looking thick. It is generally done in the outpatient department itself and you will not need anesthesia. It is well tolerated and a simple procedure. You might experience some crampy pain while biopsy is being taken.  The reports will be available in a week and you will be called to discuss the reports.  If biopsy is not tolerated or insufficient or if you are taking a pill for breast cancer you will need a camera test called hysteroscopy. A small camera is passed inside the uterus to check the lining. It can be done as outpatient or in operation theatre under anaesthesia. Even if you need anaesthesia it is a small procedure and you will be discharged on same day of the procedure.  What are the treatment options?  If biopsy and all examination reports are normal you will be reassured and no follow up will be needed unless the problem repeats. If there is uterine cancer identified you will need surgery to remove the uterus and ovaries. Remember the uterine cancers are detected early so there is very good cure possible. If vaginal dryness is the cause – you will be given hormone cream to help. If any infections identified you will be suggested appropriate antibiotics. If small polyps are the reason the polyps can be removed and sent for biopsy. If lining is thick but no cancer within then progesterone pills or coil will be suggested. Overall the treatment depends on the cause of the postmenopausal bleeding. 

What you need to know about pelvic organ prolapse? What is pelvic organ prolapse?  Uterus (womb), bladder & rectum (back passage) are the organs present within a woman’s pelvis. They are normally held in their place by ligaments and muscles called pelvic floor. If these support structures are weakened there will be bulge of organs from their natural position into the vagina. When this happens it is known as pelvic organ prolapse. Is it common to have prolapse?  It is very common especially in older women. As many women don’t go to doctor or talk about it, it might be difficult to know exactly the proportion of women who can have this problem. It is estimated that at least 50% of women over 50 years of age will have symptoms with pelvic organ prolapse. Why does pelvic organ prolapse happen?  Being Pregnant and giving birth are most common reasons for weakening of pelvic floor. More births the woman had, more difficult births, more bigger babies, more likely is the chance of you having the prolapse. After menopause it is common. Being overweight, constipation, persistent cough, and prolonged heavy lifting can also increase the chance of having the prolapse. Sometimes there is hereditary tendencies too. What symptoms will be there if I have a prolapse?  Sometimes there might not be any problem at all and we will know only when examination is done. Most of the times, it is the sensation of lump coming down is the symptom. Backache, heaviness or dragging discomfort in the vagina can be there.If bladder is also prolapsed – You may experience need to pass urine frequently, incomplete emptying, frequent urine infections. If bowel is also prolapsed – You can have constipation or incomplete bowel emptying. Some women might have to push the lump back to be able to empty bladder or bowel. Sex might be uncomfortable and lack of sensation during intercourse can be distressing. Will I need tests?  Prolapse is usually diagnosed by performing a vaginal examination. Your doctor will insert a speculum (a metal or plastic instrument used to separate the walls of Vagina) to assess the prolapse and to determine exactly which organs are prolapsing. Urine test will be done to check for infection. If you have leakage of urine special tests like Urodynamics will also be done. What are the treatment options?  If mild prolapse and no symptoms, you might choose to take wait and see option, however losing weight if you are overweight, reducing cough, avoiding constipation, avoiding heavy lifting can help to reduce worsening of the problem. Kegels or pelvic floor exercises will help to strengthen the pelvic floor muscles.If you are unable to do these exercises you will be referred to a physiotherapist to guide you doing the right way. Vaginal hormone might be recommended. Other options include pessaries or surgery. Pessary – Is a good way of supporting the prolapse. If you don’t wish the surgery or if surgery is too risky for you due to any medical condition you will be given this option. Pessary is made of plastic or silicone. There are many varieties and sizes of pessaries available. Your doctor will advise the right one for you. Most commonly used pessaries are ring pessaries. Fitting the right size pessaries can sometimes take more than one attempt. They have to be changed frequently. You have to report to your doctor if you experience any irritation or bleeding. Surgery – Choosing surgery will depend on severity of your symptoms, effect on quality of life and if other options are not helpful. There will be some risks with any operation especially if you are overweight or have any medical problems. The usual surgery that is done is removal of uterus and pelvic floor repair. Lifting up the uterus or vagina to a bone of your spine or a ligament within your pelvis are also available especially if prolapse is recurrent. Closing off the vagina will be considered only if many surgeries are unsuccessful or you are in very poor medical health. How successful is the surgery? In 75% of women surgery is successful. However in 25% of women, prolapse can come back and might require further surgery at a later date.

Bacterial vaginosis is a vaginal infection caused by bacteria. It is the most common cause of abnormal vaginal discharge that happens in reproductive-age women. It can cause a “fishy” odor and vaginal irritation in some women. Others may not have any symptoms. SYMPTOMS Most of the females with bacterial vaginosis will not have any symptoms but when they have, it includes- Burning feeling while micturation Fishy smell mostly after sex Itching Thin white, gray, or green discharge RISK FACTORS It is rarely seen in females who are not sexually active. It most commonly affects- Pregnancy Unprotected Intercourse Have an intrauterine device (IUD) Have multiple sex partners Have a new sex partner Have a female sex partner Use douches Smoking Perfumed bubble baths, vaginal deodorants, and few scented soaps Washing underwear with strong detergent CAUSES BV is due to an imbalance of natural vaginal bacterial flora. Why this happens is not clear. The role of bacteria Bacteria is present allover our bodies, but some are beneficial while others are harmful. These bacteria become infectious when number of harmful bacteria increases. The vagina is house for mostly “good” bacteria and some harmful bacteria. BV occurs when the harmful bacteria outgrows the good bacteria in number. A vagina should contain bacteria called lactobacilli. These bacteria produce lactic acid, making the vagina slightly acidic. This prevents growth of other bacteria. Acidity of vagina decreases if levels of lactobacilli decreases leading to growth of other bacteria’s. However, exact relationship of these harmful bacteria with BV is not known. COMPLICATIONS Bacterial vaginosis doesn’t generally cause complications. Sometimes, having bacterial vaginosis may lead to: During pregnancy– In pregnant women, bacterial vaginosis is linked to loss of pregnancy, early rupture of amniotic membranes, Chorioamnionitis, premature deliveries and low birth weight babies due to preterm labours. After Delivery-Postpartum Endometritis, an irritation or inflammation of uterine lining. Sexually transmitted infections– Bacterial vaginosis makes women more susceptible to sexually transmitted infections, like HIV, herpes simplex virus, chlamydia or gonorrhea. If you have HIV, bacterial vaginosis increases the chances of passing on the virus to your partner. Infection risk after gynecologic surgery- such as hysterectomy or dilation and curettage (D&C). Pelvic inflammatory disease (PID) – Bacterial vaginosis can sometimes cause an infection of the uterus and the fallopian tubes therefore the risk of infertility increases. Studies have shown that success rate of IVF decreases in BV. PREVENTION Minimize vaginal irritation- by using mild or nonscented soaps and tampons or pads. Don’t douche- douching disrupts the vaginal balance and may increase your risk of vaginal infection.  Avoid Sexually transmitted diseases- Use a male latex condom, limit your number of sex partners. Always wipe from front to back instead of back to front after using the bathroom. Wear cotton or cotton-lined underwear. Bacteria thrive in moist environments. Cotton helps wick away moisture. DIAGNOSIS The doctor will: Ask about your medical history- about previous STIs, etc. Do an overall physical exam Do a pelvic exam- for signs of infection, condition of pelvic organs Take a sample of discharge from your vagina to look for  bacteria Test your vaginal pH. A vaginal pH of 4.5 or higher is associated with bacterial vaginosis. TREATMENT Often it remains asymptomatic, but women with signs and symptoms should take treatment to avoid complications. Often antibiotics (metronidazole, clindamycin, tinidazole) are required to treat BV. This could be a tablet or a cream or gel you put into your vagina. Most females need to take treatments for 5 to 7 days. Finish full course of medicines, even if the symptoms go away. Incomplete medications course can lead to recurrence. Since BV can be spread through sex, so it is advisable to avoid sexual contact till treatment is finished. Female sexual partners should see their doctor to find out if they need treatment. IUDs users with BV can opt for other forms of contraception. To treat bacterial vaginosis, following medicaions can be prescribed: Metronidazole- This is given as oral forms mostly. Metronidazole is also be given as a topical gel to insert into the vagina. It is the most commonly used antibiotic. It is preferred over other antibiotics if the woman is breastfeeding or pregnant. Clindamycin -This medicine is available as a cream that you insert into your vagina. Clindamycin creams are known to weaken latex condoms- so take adequate precautions for atleast 3 days after stopping the treatment. Tinidazole-This medication is taken orally. Tinidazole reacts with alcohol, so avoid alcohol during treatment and for at least three days after completing treatment. Secnidazole -This is an antibiotic you take orally in one dose.  Generally it is not necessary to treat an infected woman’s male sexual partner, but it can spread among female sexual partners, so female partners should be tested and treated accordingly. It’s especially important for pregnant women with symptoms to be treated to decrease the risk of premature labour. RECURRENCE Around one-third of women whose symptoms disappear with treatment will have a recurrence within 3 months, and half will have a recurrence within 6 months. If more than three episodes occur within 12 months, the doctor may prescribe a vaginal metronidazole gel to use twice a week for 3 to 6 months. While current research shows there may be some benefit to probiotic therapy, more research is needed on the subject.

Bleeding during pregnancy is relatively common, but it can be a dangerous sign. Visit your doctor even if its spotting or it stops. What causes bleeding early in pregnancy? Having sex- mostly due to pregnancy changes in cervix An infection Smoking Implantation Bleeding- When a fertilized egg (embryo) attaches to the lining of the uterus (womb) and begins to grow. Usually occur 10-14days after conception. It is harmless. Invasive testing like Amniocentesis and Chorionic villus sampling- done to check genetic abnormalities. Hormone changes. Medical conditions- Bleeding disorders Changes in your cervix. Occasionally bleeding or spotting in the first trimester can be due to a serious problem, like: Miscarriage- loss of pregnancy before 20weeks. Almost all women who miscarry have bleeding or spotting before the miscarriage. Bleeding can be along with pain abdomen. Ectopic pregnancy-fertilized egg implants outside uterine cavity and begins to grow.  Molar pregnancy- it is growth of abnormal tissue in the uterus, instead of a baby. Molar pregnancy is rare. What causes bleeding in the Second and Third Trimesters? Abnormal bleeding in late pregnancy is considered more serious because it can lead to severe complications to mother or baby.  Placenta previa-the placenta is located in lower uterine segment, partially or completely covers the internal OS. Placenta previa is not very common in the late third trimester, occurs in one in 200 pregnancies. It leads to painless bleeding. Placental abruption- In about 1% of pregnancies, the placenta separates its attachment on the uterus before or during labour. Placental abruption is very dangerous for the mother and baby both. It is often associated with severe abdominal pain, severe bleeding from the vagina, tender uterus, and backache. Uterine rupture-In rare cases, a scar from a previous C-section or uterine surgery can tear open during pregnancy. Uterine rupture can be life-threatening, and requires an emergency C-section. It can present with pain and tenderness in the abdomen. Vasa previa- In rare circumstances, baby’s blood vessels in the umbilical cord or placenta lies just above the opening to the birth canal. It can be fatal for the baby because the blood vessels can tear anytime, causing the baby to bleed severely and lose oxygen. It might be associated with abnormal fetal heart rate and excessive bleeding. Premature labor- Vaginal bleeding late in pregnancy can be due to your body getting ready to deliver. Preterm labour is when labour starts before 37th week of pregnancy. Other symptoms of preterm labor include contractions, vaginal discharge, abdominal pressure, and lower backache. Other causes of bleeding in late pregnancy are: Sex Internal examination by your doctor. SHOW- Mucus plug which was inside cervix during pregnancy comes out, as the cervix is getting ready for labour to start. It can happen anytime from few days before contractions start or during labour itself. Injury to the cervix or vagina Polyps- usually painless bleeding  Cancer What should you do if you have bleeding or spotting during pregnancy? Seeking medical attention immediately is must in case of- Heavy bleeding Bleeding with pain or cramping Dizziness and bleeding Pain in your belly or pelvis Passing some tissue with blood Keep a record of amount of bleeding, if it gets heavier or lighter, and number of pads you are using.  Check the color of the blood.  Your provider may want to know. Bleeding can be brown, dark or bright red. Do not use a tampon, douche or have sex during bleeding. Inform your Doctor if you are Rh Negative. Diagnosis To find out the cause of bleeding, you will need to have a detailed vaginal or pelvic examination, an ultrasound scan or hormonal levels through blood tests. Your doctor will inquire about other symptoms, like as abdominal cramp, dizziness and pain. Sometimes it might not be possible to find out what caused the bleeding. How are bleeding and spotting treated? Treatment depends on cause of the bleeding.  Rest is very important part of treatment during bleeding. Take time off from work and take rest for a little while. Don’t have sex, douche or use tampons. If your symptoms are not severe and you are preterm-you’ll be monitored and can be kept in hospital for observation. Severe Symptoms and term gestation can mandate delivery.

What are uterine polyps? Uterine polyps or endometrial polyps are the growths that happen with in the lining of the uterus (womb- where in the baby grows in pregnancy). The polyps can be attached to the lining of the uterus by a thin stalk or thick broad base. They are usually no cancerous although sometimes we have to rule out precancerous or cancerous changes in them. Polyps can sometimes cause irregular bleeding or problems with fertility  Who can have uterine polyps? Uterine polyps are more likely to develop in women of 40-50 years age. They can also happen after menopause but rare in women under 20 years Women who are overweight or obese or those with high Blood pressure or those who use tamoxifen (medicine used in treatment of breast cancer) are more likely to develop uterine polyps. What are the reasons & why some women develop uterine polyps? The exact reasons are unknown Hormonal changes especially retrograde plays a role in causing the lining of the uterus to get thickened and thereby causing polyps. What symptoms can women have when they have uterine polyps? Women might experience heavy menstrual bleeding, irregular or unscheduled bleeding, spotting or bleeding in between periods, fertility problems. Most of the time polyps might not cause any problems and are detected at scans done for various other reasons. What tests are done to know if there is uterine polyp or not? After taking details of your symptoms and thorough clinical examination your doctor might ask for ultrasound scan. Pelvic ultrasound done from vagina is used to detect uterine polyps. As ultrasound uses only sound waves it is safe. Sometimes it is challenging to detect some polyps especially if lining is thicker or irregular. Saline can be passed through vagina into the uterus and scan done to get clear view of inside of the uterus. This is called saline sonogram or sonohysterogram. Sometimes biopsy done for lining if uterus can detect polyps. However polyps can be missed at biopsy. Hysteroscopy is considered to be good standard test to detect and treat uterine polyps. A small camera is passed through vagina and cervix into the uterus and fluid is used to distend the uterine cavity. Direct visualisation of lining of uterus is possible through this test. Major advantage is removal of polyps can be done at same time as the test. What treatment options are available for uterine polyps? Not all polyps need removal especially if women don’t have symptoms. However if irregularities of bleeding or polyps that are suspicious of cancer or precancerous or in women with history of miscarriages or fertility problems and in women polyps are noted after menopause removal is suggested. Medications – hormones like progesterone can be used for temporary treatment. Hysteroscopy and polyp removal is generally the treatment of choice. It enables not only the diagnosis but also ensures complete removal of polyp under vision thereby reducing the regrow of the polyp. Some polyps might reoccur despite complete removal. Just doing curettage without using the cope is not ideal. Additional surgeries might be required if polyps are precancerous or cancerous or recurrent. Can we prevent formation of uterine polyps? There is no way to prevent formation of polyps. However by reducing obesity and controlling high blood pressure we can prevent polyps indirectly. Those who are on tamoxifen medicine for breast cancer will need regular gynaecology check up to detect early. In some premenopausal women who have recurrent polyps and those who have completed family LNG -IUS (progesterone hormone containing coil) has shown to reduce the recurrence.