Women's Health 2003 -- Jane Harrison-Hohner, RN, RNP. -- 01/08/03
By Jane Harrison-Hohner
If your wish is to be healthier from head to toe, get off on the right foot by reading our members' women's health questions from WebMD Live. Our guest was WebMD's own GYN Issues message board expert, Jane Harrison-Hohner.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Welcome to WebMD Live. Today our guest is WebMD's own "GYN Issues" message board expert, Jane Harrison-Hohner, RN, RNP.
Member: I am asking a question for my wife, age 45, who does not have access to the Internet at this time. She has had pelvic pain and groin pain on her right side for about eight months. This seems to be associated to her period and to intercourse, but not completely. She went to our family doctor who ordered a series of GI tests -- all of which indicated no problem. She has not seen an ob-gyn in several years and the one she did have has moved from the area. On a recommendation from a co-worker she had an appointment with an ob-gyn. This doctor performed an internal exam and reviewed the CT scan and ultrasound images (these tests had been ordered by other doctors). The ob-gyn said that there was a large complex cyst on her left ovary and a smaller simple cyst on her right side. Given her age and the fact that we do not intend to have more children (we have four), the doctor suggested that she have a hysterectomy along with removal of the ovaries. He said she might optionally leave one of the ovaries if it can be "cleaned up." He believes she has endometriosis. However, WebMD indicates that a laparoscopy should always be performed to verify the diagnosis. The doctor seems quite confident in the diagnosis and a laparoscopy would mean two surgeries if the diagnosis is confirmed. Do you have any recommendations? What is the recovery time from a laparoscopy and a hysterectomy? Any other information would be welcome.
Harrison-Hohner: Thanks for being an advocate on behalf of your wife. According to the CT and ultrasound it sounds as though the right lower quadrant pain may not be related to a simple ovarian cyst. By contrast, the left ovary with its "compound cyst" suggests something more concerning. Neither of these cysts may be the cause of her right sided pain. Apparently, the GI studies are normal. That is very reassuring as we find it's important to rule out all the body systems in right lower quadrant pain. Given the history that you shared about worsening pain with menstrual period and intercourse, I would also be suspicious of endometriosis. The endometriosis can cause scar tissue, also known as adhesions, which is strongly associated with pain with intercourse.
While she could choose to have a total hysterectomy including oopherectomy, that is a very irrevocable decision. In spite of the two surgeries she may wish to consult with another ob-gyn or consider getting a laparoscopy. A laparoscopy can evaluate the left compound cyst. A laparoscopy can also evaluate the degree or extent of endometriosis. If a woman is having significant pelvic pain, studies have shown a hysterectomy usually leads to benefit. Nonetheless, once the uterus and ovaries are removed she will have other decisions to make, as she will be menopausal.
As for the questions about recovery, a laparoscope recovery is very brief -- a week or so, at most. An abdominal hysterectomy, because of the abdominal incision and handling of the bowel, can have a recovery period of four weeks. Thus, the degree of her pain is probably going to be the governing factor in the decision. If she's having significant pain, then the hysterectomy is probably the direction she would want to go. If her pain is less severe, she may wish to have a laparoscope evaluation of ovaries and accurate diagnosis for endometriosis. If she does have endometriosis, she may be a candidate for medication management. She can always choose to have the more extensive surgery at that point should that become necessary. Thanks for taking the time to write that question with such good history.
Member: Over the last three years I have been taking Vioxx for arthritis and I am 33 years old. Over the last year I have been having light bleeding between my periods. I stopped taking the Vioxx and my periods returned to normal but due to the pain from the arthritis I began taking the Vioxx again. I have begun having the light bleeding between my periods again. What effect does Vioxx have on your periods and should I discontinue it? I also have been unable to get pregnant. So does Vioxx also have an effect on ovulation and could that be the problem? I have had a normal exam. Thank you.
Harrison-Hohner: Actually that's a really interesting question. Let's address the fertility question first. There is some evidence in the fertility literature that women who take NSAIDs (Advil, Vioxx, Aleve, etc) may have altered prostaglandin production necessary for the egg to be released. Now, this may not be the situation with you as there are many reasons for inability to conceive, but it's worth thinking about if all other elements of a fertility workup are normal.
As to why you are having the light mid-cycle bleeding with the Vioxx, I am less clear. We know these medications can make the blood thinner. Women who use these medications, especially if they take aspirin as well, have increased risk of bleeding -- it's less easy for them to coagulate. It may be, although this is just speculation, that the normal change in estrogen level that happens right around the time of ovulation has allowed a small amount of uterine lining spotting to occur. Another consideration: If your arthritis is of the rheumatoid rather than osteoarthritis type, the presence of other autoimmune factors may be a culprit. My recommendation would be to continue on the Vioxx as you need it for day-to-day activities. If you are still unable to conceive, or are trying to conceive actively, you should consult with a gynecologist who has expertise in fertility.
Member: About three months ago I noted nipple discharge. I have had a mammogram, ultrasound and ductogram, because the mammogram showed a dilated duct. When doing the ductogram they broke the duct. Since then the drainage hasn't been quite the same, but I think I feel a lump, which I think I felt before. I did have an appointment with a general surgeon who mentioned doing a blind biopsy, but he didn't feel anything abnormal. So he didn't feel it was necessary. I was told to repeat tests in three months. That sounds like a long time to wait to me. Should I get a second opinion? I am worried. I am only 31, never been pregnant, no family history, until recently when I learned that a cousin has it in both breasts.
Harrison-Hohner: It sounds as though you had a good workup in getting the ductogram and mammogram for the nipple discharge. The three-month recommendation makes sense to me and I do believe that if the surgeon had significant concerns he would have advised immediate treatment. I always believe that if the patient has significant concerns that it's worth getting a second opinion. Your age puts you at a statistically lower risk for breast cancer. Yet I understand your concern given your new family history for breast cancer. I always suggest a second opinion if the woman perceives that something may still be going on for her. I will tell you frankly that I have referred women for a lump in one breast that I had worries about and that I had missed cancer in the other breast, which I had nothing but just a concern about.
In conclusion, I suspect and hope that the ductal problem is a benign one. If it were me,
I would probably wait the three months. But since it's you, I suggest that you get the second opinion if you have significant concerns.
Member: I am a 44-year-old woman. I have always had regular periods, but the last couple of years they have become very heavy (at least the first three or four days) and last at least seven days. I wear super plus tampons and a regular pad (both being soaked sometimes in and hour or two). What brought me to my doctor was I started having my period twice in a month. Then the next month was normal. Then the next month I had my period it lasted 16 days and still wasn't stopping. My doctor gave me a Depo-Provera shot to stop the bleeding, which it did in a couple of days. I did not bleed for about a week and half until I had my D&C. I never did just spot; I had bright red blood not as heavy as my period but more than spotting. It has been 15 days and I am concerned if this is normal. My doctor says as long as it is not heavy I should not be concerned. I have an appointment in two weeks. I was slightly anemic, which has been corrected with vitamins. I must mention my D&C showed a lot of tissue growth and polyps, but was benign. My doctor said he may have left some in there and that is why I might still be bleeding. He said we may have to look at other things. Do I have reason to be alarmed?
Harrison-Hohner: What you describe is so typical for those of us in our 40s. As our ovulations become less frequent and less progesterone is produced, the result is irregular and very heavy periods. Even in the women who ovulate regularly, our cycles in our 40s typically have this pattern of heavy, heavy bleeding for 24 to 48 hours. In your specific case your physician gave you a large dose of synthetic progesterone to try and remedy the problem. The good news is: Your D&C showed simple hyperplasia and benign polyps. Undoubtedly, your polyps were a contributing factor to the erratic bleeding.
The question is what to do now. There are a variety of possibilities. Some of these include use of a hysteroscope to visualize the interior of your uterine cavity. Through the scope, all remaining polyps and areas of thickened tissue can be removed. You might then be started on some type of hormonal medication, like low-dose birth control pills, Depo Provera, or Cyclic Progesterone. Another option would be to watch and wait and see if the aberrant cycles return. Also, either the progesterone IUD (Mirena) or what is called endometrial ablation -- that is destruction of the uterine lining to reduce subsequent bleeding -- could be considered. This can be done safely using a thermal balloon or other techniques.
Lastly, the main consideration would be fertility issues. Perhaps by age 44 you have finished with child-bearing and in that case any of these treatments would be satisfactory. If you are seeking pregnancy, the better choice would probably be ovulation induction. I hope that one of these treatments will rid you of the troublesome heavy bleeding. Believe me, we all feel for you and many of us have been there.
Member: Hi Jane. I 'm 24. For the past five days I've been having major pain in my leg and lower stomach area. Last night I took a pregnancy test -- it was positive. I want to know, is it normal to have these pains? Please note the pain makes me cry.
Harrison-Hohner: If you have a positive pregnancy test and especially if you are having lower abdominal pain, please make contact with an ob-gyn. Depending upon your actual length of pregnancy, the pain could be from a variety of different things. Worst-case scenario would be if you are 10 weeks pregnant or less and are experiencing a tubal or ectopic pregnancy. If you are having really severe pain and you cannot be seen soon you may wish to go to an urgent care facility. Best-case scenario would be a totally normal pregnancy with perhaps pain coming from the normal corpus luteum cyst. It is very uncommon to have a severe pelvic infection while pregnant, but that's also a possibility. If you were my patient, I would want to see you in my office, get a reliable pregnancy confirmation, and an exam with some lab work. This may include a urine test for bladder infection and an ultrasound to evaluate the ovaries. I am sorry I can't give you a more detailed analysis but you NEED to be seen.
Member: Hi Jane. My question is Depo Provera-related. I was on Depo from March 2000 to December 2001, and quit due to the weight gain. I finally had a period in October of 2002, and haven't had one since. The period in October was for 25 days straight. I am 24 years old, with one child (almost 3 in Feb.). Can you tell me when I can expect to be back to normal or is pregnancy a big possibility? I've taken two pregnancy tests (both negative) and have an appointment for the 30th for the doctor, but I am nervous and would like some answers if you can help me.
Harrison-Hohner: The longest documented return to fertility (pregnancy risk) after stopping Depo is 18 months. Nonetheless, one cannot count on that. If you are having unprotected sex you could get pregnant before your next period. My best guess as to what's going on is that you are having lingering Depo effects. The 25-day cycle in October suggests that you are still not ovulating regularly.
I would suspect when you see the doctor on the 30th they will look for other causes of non-ovulation such as thyroid or pituitary growth (blood test for TsH and Prolactin). If those are normal, the doctor may give you five to 10 days of Provera pills and see if you have a flow. If you have a flow in response to Provera pills that tells us you are making enough estrogen to make a lining but simply are not ovulating so that the lining can be shed in an orderly fashion. If in fact you don't have flow as a result of the pills, that tells us you are not making enough estrogen to make a lining. That is a more complex scenario.
Additional lab work may need to be done. If all the lab work comes back normal, they may suggest putting you on birth control pills for six to 12 months. At the end of that time they would have you go off and watch and see what happens with your own natural cycles.
One last thought: If you were started on the Depo because of history of irregular cycles you may be returning to what is "normal" for you. Good luck with the doctor on the 30th.
Member: I am 35 and a mother of three. I had my tubes tied and have my period regularly. All of a sudden I started gaining weight just in my stomach. I stay tired a lot now and have to urinate very frequently. It's almost as if I'm pregnant again. Is there a chance that I could have fibroid tumors? I also have heavy bleeding and clotting when I have my period.
Harrison-Hohner: Your assessment of fibroid tumors is a possibility. If you have a fibroid on the front of the uterus it can press against the bladder just as a large uterus from pregnancy can. That could cause frequent urination and a sense of abdominal enlargement. Fibroids can also disrupt uterine blood flow prompting heavy bleeding.
The important thing for you is to go to a gynecologist and have an ultrasound done of the uterus. This would identify any obvious fibroids throughout the uterus. Given your fatigue and heavy bleeding, you should also have a blood thyroid test; low thyroid can also cause mild weight gain. If it's neither fibroids nor thyroid, further investigation will have to look at other less common causes.
Lastly, I would suggest getting a test for urinary tract infection just to be sure that's not part of the problem. In the end, each of these things may have a different ideology. From the gyn perspective, fibroids and thyroid would be the only things I could think of where all of the symptoms are covered.
One last thought is diabetes. That can be easily checked for as well. Hope that you can find the cause for these problems readily.
Member: Jane, I was wondering what are the odds of getting pregnant, while on her four or fifth day of her cycle, by preejaculate on my hands
Harrison-Hohner: The chances are very unlikely, but if she has concerns, make sure she has a pregnancy test if her period does not arrive on time.
Member: Hi, I had sex with my boyfriend thre days ago and I lost my virginity. I'm still bleeding but not too much. Is it normal? How long should I bleed after first-time sex?
Harrison-Hohner: Many women have no spotting or bleeding after the first time they have intercourse. Some have bleeding like a light period. What I suggest is if the bleeding persists, or increases in amount, that you go see a family planning clinic or gynecologist. Now that you are sexually active is a good time to establish a relationship with a gynecology clinic. I suspect everything will be fine and that there is no reason for concern. But if the bleeding continues, have it checked out, and it offers the opportunity to talk about sexual issues and birth control.
Moderator: We are out of time. I'm sorry we couldn't get to all of your great questions. Thank you Jane Harrison-Hohner, and thank you members for joining us today. For more information, please visit Jane on the GYN Issues message board. Check out our news stories, features and archived interviews with experts - visit the Women's Condition Center and the Healthy Women Center on WebMD.
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