Dear An: Let's take each of the adverse symptoms individually, then discuss embolization, OK?
1. Urinary incontinence--if the fibroid is large enough to press against the bladder, and especially if the fibroid is on the front wall of the uterus (pushing out and restricting bladder capacity) then removal of the fibroid should fix the incontinence. However, there can be several types of incontinence--sometimes coexisting in the same woman. So if other types were present that could influence successful urinary outcome.
2. Low back pain---an enlarged fibroid uterus can be linked to a low, dragging, heavy pain which can radiate to the back. Again, if the fibroid was the sole cause of the pain, removal should assure success.
3. Pelvic pain with intercourse--fibroids by themselves tend not to be tender unless they are undergoing degradation (blood flow is cut off). But an enlarged uterus can make intercourse less comfortable.
Here from the National Library of Medicine site is a study about fibroid linked symptoms:
Fertil Steril. 2003 Jan;79(1):112-9. The Ontario Uterine Fibroid Embolization Trial. Part 1. Baseline patient characteristics, fibroid burden, and impact on life. Pron G, Cohen M, Soucie J, Garvin G, Vanderburgh L, Bell S; Ontario Uterine Fibroid Embolization Collaboration Group.
Department of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada. email@example.com
To determine baseline characteristics of women undergoing uterine artery embolization (UAE) for symptomatic fibroids. DESIGN:
Five hundred fifty-five women undergoing UAE for fibroids. INTERVENTION(S):
Baseline questionnaires completed before UAE. MAIN OUTCOME MEASURE(S):
Questionnaires were analyzed for demographic, medical, and gynecologic histories. Fibroid symptoms, impact of symptoms, previous consultations, and treatments were also analyzed. RESULT(S):
The Ontario cohort (66% white, 23% black, 11% other races) had an average age of 43. Thirty-one percent were under age 40. Most women were university educated (68%) and working outside the home (85%). Women reported heavy menstrual bleeding (80%), urinary urgency/frequency (73%), pain during intercourse (41%), and work absences (40%). They experienced fibroid-related symptoms for an average of 5 years and consulted with on average of three gynecologists before UAE. High fibroid life-impact scores were reported by 58%. Black women were significantly younger (40.7 vs. 44.0 years), more likely to experience symptoms longer (7 vs. 5 years), and more likely to undergo myomectomy before UAE (24% vs. 9%) than white women. CONCLUSION(S):
Our study illustrates that large numbers of women with highly symptomatic fibroid disease are averse to surgery despite their burden of suffering and are actively seeking alternatives to hysterectomy.
An_250546, your GYN or interventional radiologist can give you the most for sure answers about the suitability of your specific fibroid for an embolization. Size of the largest fibroid is one of the primary considerations (usually anything smaller than a 16-20 week pregnant uterus size is OK). If you have not yet consulted with a clinician who specializes in UAE, that would be my advice.
Dear gracie: MULTIPLE literature searches at the National Library of Medicine site on back pain after endometrial ablation (EA) did not yield any good information about treatment. The most frequent reason cited seemed to be adenomyosis (infiltrating endometriosis into the muscular wall of the uterus). One of the articles was even printed in a journal for chiropractors. I could not find any reference to back pain caused by the actual EA operation (eg. no evidence for nerve involvement).
If your GYN seems stumped by this new onset back pain perhaps you may want to consult with someone who specializes in back pain (ie orthopedist MD). Hopefully they would have some bteer insights about the mechanism for the pain--and its treatment.
Dear jewelsmaid: Anon_6061 has spoken correctly. The CA-125 has very poor specificity in premenopausal women. One can have an elevated level with fibroids, endometriosis, functional ovarian cysts, diverticulitis, and pelvic infections. It is ordered as part of a work up for a complex ovarian cyst, but it is not diagnostic per se. The MRI will add much more specific information--with the most accurate diagnosis being made when a cyst is removed.
In my clinical experience, if ovarian cancer is strongly suspected, the GYN will usually tell the patient. Moreover, if ovarian cancer is advanced enough to create abdominal bloating caused by ascites fluid this can usually be seen on ultrasound.
Gosh, we all hope that your cyst ends up being from endometriosis or some other benign diagnosis. Kindly write us back with your outcome as other women in the future will find your post via internet search.
Dear Mitchhattingh: Mountainmom is correct, low thyroid can create abnormal bleeding patterns by interfering with regular ovulations. Multiple literature searches at the National Library of Medicine site on thyroid function and antidepressants did not yield any good citations on antidepressant caused hypothyroidism. Low thyroid levels have been linked to depression; thyroid hormones can be used as an adjunctive treatment with antidepressants. Lithium was the only psychiatric medication clearly linked to causing thyroid problems. So while it is always good to check thyroid it may not be the major culprit in your case.
You mentioned that you are currently perimenopausal. One of the hallmarks of this transition is variability in ovarian hormone levels. For example, as FSH levels rise that can actually increase estrogen production in the ovaries as multiple follicles are recruited. The amount of estrogen you are taking is not enough to completely suppress spontaneous ovary activity. You are taking less than half the amount used in a very low dose birth control pill. This is plenty to handle hot flashes, but not enough to prevent ovarian follicles from developing.
You did not mention the exact dose and regimen of progesterone you are using. It is also POSSIBLE that the extra bleeding is a result of needing additional progesterone to oppose the estrogen effects on your uterine lining. As you may have read, if the uterine lining is like grass or lawn, estrogen is like the fertilizer (causes a thickening of the lining ), and progesterone is like the lawnmower (keeps the lining thin by three different mechanisms). This is why DepoProvera (high dose synthetic progesterone) brings about a thin lining, and why birth control pills (relatively progesterone dominant) bring about shorter, lighter periods. It is also why women who miss ovulations (no progesterone produced) are at a greater risk for a too thick lining.
Finally, there are women who report increased breakthrough bleeding when under stress. These include women on and off hormonal medication. Alas, there are no published studies in the medical literature documenting this!
Bottom line, you really need to inform your GYN about the upswing in bleeding. They may want to make a change in your medication regimen, do an ultrasound to check the thickness of your uterine lining (this would visualize any ovarian cysts as well), or some other investigations. If indicated a TSH (thyroid blood test) could be ordered.
Dear MRoquo: The signs and symptoms of a blood clot in the leg often include: swelling of the impacted leg, a site specific area of tenderness, often heat/redness over the specific area of the clot. Itching is not a typical feature of a DVT (deep vein thrombosis) of the leg.
Given that you have had this leg itching for the past two months, and that it seems to be spreading, I would really urge you to see your primary care MD or clinic. They can make the most correct diagnosis and prescribe the appropriate treatment. My best GUESS is that it is a dermatology problem as you suspected.
Dear halcal: You are correct, the nonhormonal, copper IUDs (eg Paragard) do not tend to cause absent or very light flows as the hormone containing Mirena IUD can. Rather, many women report an increased volume of flow with the Paragard type.
You mentioned that, once the Paragard was removed in September, you had normal cycles until January and February when suddenly your flows were "too light." Once pregnancy is ruled out there are several POSSIBLE explanations for a "too-light" flow" in a woman not using hormonal forms of birth control:
1. Lowered estrogen levels--this is more likely to be the case in a woman around the time of menopause.
2. Elevated prolactin levels---prolactin is produced from the pituitary gland. Levels can be elevated from a benign pituitary adenoma or from certain psychiatric medications.
3. Missed ovulations--with a missed ovulation the lining of the uterus does not shed all at once. This can result in a missed flow, a too-light flow (just part of the top layer is shed), or even prolonged/erratic flows.
The most common culprit would be reason number 3. Causes for not ovulating are multifold: low thyroid, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with partners, money worries), increased body weight, anorexia, rotating shifts at work, etc. If you have abdominal or pelvic pain you MIGHT have an ovarian cyst.
If your cycle has not naturally reset itself next month you should see your GYN or clinic. If you develop pain or pregnancy symptoms you should be seen promptly.
Dear An_250256: As you have read earlier in this thread, a decidual cast may be more common after a withdrawal from progesterone medication. Usually this tends to be relatively higher doses as opposed to medroxyporgesterone/Provera 10mg. Yet you had what appeared to be a cast. A true diagnosis can only be made by a pathologist with the specimen under the microscope.
In your specific case, my best GUESS is that a cast is less of a concern to your future fertility that some of the other elements you mentioned. First and foremost, it sounds like you are doing everything right in terms of lifestyle. Kudos to you!
Fortunately, most women, following a single documented miscarriage do have a normal pregnancy following that sad event. That you did conceive after ceasing birth control pills is encouraging. This means that ovulations were occurring. Then following the miscarrriage/D&C, the months without a flow would suggest that ovulations temporarily ceased. This could have been triggered by the stress of the loss and D&C. The prolonged spotting can arise in the absence of ovulations as well.
As you may have read, in a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month. The good news is that you have enough estrogen to make a lining that does shed.
In a normal cycle, progesterone production increases following ovulation and release of an egg.. Progesterone "stabilizes" the uterine lining in preparation for a possible implantation of a new pregnancy. If you are not pregnant that month the levels of estrogen and progesterone fall, triggering the release of the uterine lining—your period.
So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation associated progesterone. Thus, the hormone levels don't decline, and the lining stays up inside the uterus—your missed period. Alternatively, the built up lining can begin to shed on its own creating erratic bleeding patterns which are usually "too-light" or super heavy and prolonged. This is why progesterone medication is used as a treatment for missed flows or erratic bleeding.
Unless you are a competitive athlete with low caloric intake and/or very low body fat, the issue of athletic amenorrhea/menstrual dysfunctions seems less likely. Your own OB/GYN can give you the best assessment for this. If you do not adhere to this category then your only "roadblock" may be regular ovulations and progesterone production. If you are age 30 or less it is reasonable to try for conception for up to 12 months. If you are over age 30-32 then a more formal work up may be indicated after 6 months of trying to conceive.
I'm really sorry that you have had to go through the missed miscarriage of your very much desired pregnancy. It sounds like your OB/GYN is taking that accepted "wait & see" attitude with the expectation that you will conceive soon. I feel sure that if there were specific, overt problems that they would be doing more interventions and not doing the "watch & wait," "natural" approach.
Dear An: You may have what one uro-gynecologist friend calls "The UTI That Isn't". Here are some possible explanations:
1. Urethral Syndrome While the symptoms of frequency/urgency/pain are present in almost all true UTIs, 30-50% of patients with these symptoms do not have significant bacteria in their urine (Najar, 2009). However, many of those without bacteria may have white blood cells (sign of infection or inflammation) in their urine. This likely reflects the presence of other infections which may not be bacterial. The presence of white blood cells, no bacteria, and UTI symptoms is the one common description of "urethral syndrome."
Many of the organisms thought to be causes of urethal syndrome are also causes of vaginal infections. Included in this category are Chlamydia, Ureaplasma urealyticum, gonorrhea and trichomonias. In a study of 63 women with urethral syndrome (Mutlu, 2001), evidence for Chlamydia was found in 38% of the group. The organism Ureaplasma urealyticum was identified in 192 women with urethral syndrome (Skerk, 2001).Less commonly, a genital herpes lesion within the urethra can prompt urinary symptoms. Even a vaginal yeast infection, while it does not infect the urethra, can be associated with pain as the urine stream touches irritated skin on the vulva--but you have been treated for this.
2. Overactive Bladder Syndrome Overactive Bladder (OAB) can be distinguished from a UTI, or urethral syndrome, by the absence of any type of infection. Moreover, OAB does not cause pain with voiding. The hallmark of OAB is pronounced urgency and frequency. Many women have episodes of incontinence where large amounts of urine are suddenly released---often as they run for the toilet. Most GYNs are adept at diagnosing OAB; it can be confirmed by urodynamic studies. OAB is thought to be caused by the inappropriate firing of nerves in the bladder wall. These impulses tell the brain that the bladder is full and needs to be emptied, even if there are only small amounts present. Treatments include Kegel exercises, bladder training, lifestyle changes, and medications to decrease the inappropriate urge to void.
3. Anatomic Abnormalities Less commonly, pain coupled with urgency and frequency may indicate an anatomic problem. Fletcher and Zimmern (2009) list urethral diverticulum, a cyst of the Skene's gland, and strictures/narrowing of the urethra as conditions to be ruled out. A urethral diverticulum is a small "pouch" in the urethral canal where urine can collect. Skene's glands are located on either side of the urethra. These glands can develop a cyst, or an abscess, which would narrow the diameter of the urethra. A stricture of the urethra would also narrow the outlet through which urine needs to pass.
4. Interstitial Cystitis/ Painful Bladder Syndrome (IC/PBS) IC/PBS is a characterized by urinary frequency, urgency, and lower abdominal pain where no identifiable pathology can be found (Butrick, 2003). It can be misdiagnosed as chronic UTI, OAB, or even chronic pelvic pain. Unlike a UTI, pain tends to improve with urination; unlike OAB there is an element of pain. Unlike chronic pelvic pain, one study (Warren 2008), found that pain above the pubic bone and pain in the urethra were more common than genital pain among 226 women with IC/PBS.
Anon_240957, as you can note, not everyone with urethral syndrome has evidence of infection (ie white blood cells or positive bacterial screens). It's OK to let your urologist know that the symptoms are still present. In some cases medications may be used (even pyridium or imipramine) to treat the symptoms just until the pain receptors stop firing without an apparent cause. I remember one patient who had a series of multiple, confirmed UTIs which left a residual of UTI-like symptoms despite sterile urine cultures.
Dear An: I agree with Georgiagail, the timing and brevity of the spotting do suggest ovulatory bleeding. Right before ovulation there is a brief spike of estrogen. When this level drops back down to normal, the sharp decline can destabilize the lining of the uterus leading to spotting/bleeding. Some women have this sign of ovulation every month; others only rarely. Fortunately the amount is usually scant and brief in duration.
Some other possible causes of erratic spotting can include a new chlamydia infection (unlikely if you are both monogamous). polyps of the lining of the uterus (way more common in midlife women), or missed/erratic ovulations (usually there will be a history of missed/irregular periods). Untreated low thyroid can be linked to missed ovulations and erratic bleeding.
If your erratic bleeding persists, or you develop other symptoms (eg pelvic pain from an infection or ovarian cyst) see your GYN or local family planning clinic. Hopefully, since it never happened before, this is an isolated episode of ovulation-linked spotting. Oh yes, if this is ovulation spotting the possibility for conception is elevated.
Dear An: Thanks for your personal experience with endometrial ablation used as a treatment for heavy periods caused by a fibroid. You are correct, uterine artery embolization (UAE) can be used to cut off the blood supply to fibroids. Some of the considerations used to decide who is a candidate for UAE can include: size of fibroids, and number of fibroids. If another reader is interested in this treatment option here is an excellent link to more information:
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