Dr. Barry Dworkin » Gynecology

Medications can soothe menstrual cramps

Dr. Barry Dworkin — Wed, 24 Sep 2003 20:57:45 +0000

Originally published in The Ottawa Citizen September 24 , 2003

Original Title: Cramping my style

It is the most common gynecologic problem women face in their lives. Every month it can wreak havoc in a woman’s ability to function at work, interfere with social interactions and family life. Even after it passes it looms over her shoulder ready to inflict pain and suffering in a seemingly unending cycle.

Painful menstrual cramps (dysmenorrhea) affects up to 90 per cent of women. Although varying in degree, many can attest to the absolute misery they experience each month.

Two types of dysmenorrhea exist: primary and secondary. The former occurs in the absence of any demonstrable pelvic disease. Secondary dysmenorrhea can be caused by tumours, fibroids, sexually transmitted disease, intrauterine devices (IUDs) and endometriosis among other factors.

Primary dysmenorrhea usually begins within three years of the onset of the menstrual cycle (menarche). About 60 to 90 per cent of adolescent females report symptoms of dysmenorrhea. Why does this occur?

The body of evidence suggests a sequence of events that cause pain. During a normal menstrual cycle, estrogen and progesterone will stimulate the cells lining the inner uterine wall (endometrium) to buildup of a substance called arachidonic acid.

When bleeding begins, biochemical reactions within the disintegrating endometrium change arachidonic acid into prostaglandin F2alpha (PGF2alpha) and other substances. PGF2alpha levels are greatest in the first two days of the menstrual cycle.

This prostaglandin produces intense prolonged contractions of the uterus that will restrict blood flow into the uterine muscle (myometrium). The result is similar to an attack of angina; reduced blood flow starves the muscle tissue of oxygen. The muscle responds by using other energy sources that do not require oxygen in order to survive. The net result of this process is a buildup of metabolic byproducts that sensitize the nerve endings that cause uterine pain.

The pain usually coincides with bleeding and ends 12 to 72 hours thereafter. The pain can remain confined to the lower abdomen but for some women it will radiate to the back and legs. Nausea, vomiting, diarrhea, fatigue, headache and malaise can accompany the pain.

The diagnosis of dysmenorrhea requires a thorough medical history and physical examination. The physician needs to know whether the cause is due to gynecologic disease as mentioned earlier or is indeed primary dysmenorrhea.

The medical history should include the age of the woman when she first started her period, the number of days between the first day of each period, the dates of her last two periods, the amount of blood flow, the total number of bleeding days and whether she has any spotting between her periods.

Are there other symptoms with the pain? How severe is it and does it radiate to other regions? Does she experience painful intercourse? Are bowel movements painful? Is the pain unrelated to her period and does it prevent participation in normal daily activities and responsibilities?

What medications have been used to relive the symptoms? Did it work? Did the use of nonsteroidal anti-inflammatory medication (NSAIDs) like ibuprofen (Advil, Motrin) help relieve some or all of her pain? If it did provide pain relief, the diagnosis is more likely to be primary dysmenorrhea.

The pelvic exam is usually normal in women with primary dysmenorrhea. Women with gynecologic disease usually have some physical findings but some may also have a normal examination.

The mainstay of treatment is NSAIDs. This class of medications will block the synthesis of prostaglandins. Between 70 to 85 per cent of women will respond favourably to this treatment. A trial of naproxen (Naprosyn), mefenamic acid (Ponstan) or other NSAID follows if ibuprofen (800 milligrams every four hours) fails to work (NSAIDs can cause stomach upset and bleeding in some individuals. Please discuss dosing with your physician or pharmacist).

The birth control pill is an option for women if NSAIDs are ineffective. It will block the production of arachidonic acid thereby reducing uterine contractions and pain during her period.

Women who do not respond to NSAIDs and oral contraceptives may have a gynecologic disease such as endometriosis causing their pain.

There are some small clinical trials that show other methods relieved symptoms. One trial demonstrated that after a two-month low fat-vegetarian diet women reported a significant decrease in pain intensity.

Another study reported pain reduction using a fish oil supplement (1080 mg eicosapentanoic acid, 720 mg docosahexanoic acid).

The use of a TENS (transcutaneous electrical nerve stimulation) machine seemed to provide pain relief. Physiotherapists often use this device to treat muscle injuries.

These preliminary studies suggest that other modalities may be effective in treating primary dysmenorrhea. Evidence remains scant regarding the effectiveness of acupuncture, herbs and other treatments.

Women should not have to suffer with this condition. Consult your doctor about treatment options.

No related posts.

Cervical cancer tests save women’s lives

Dr. Barry Dworkin — Tue, 26 Nov 2002 20:53:29 +0000

Originally published in The Ottawa Citizen November 26, 2002

Original Title: A Proven and Effective Means of Fighting Cervical Cancer

Medical research strives for the day when the diagnosis of cancer will no longer evoke fear. The goal to develop effective screening and treatment strategies to eradicate this disease continues to move forward. One of the ongoing success stories in this battle is the screening and early treatment of cervical cancer.

Cancer of the cervix is the third most common malignancy in the United States and the eleventh among Canadian women. Approximately 1300 Canadian women will develop cervical cancer and 400 will die this year. Worldwide, it is the second most common form of cancer in women and the leading cause of cancer death in developing countries. Why this discrepancy?

Cervical cancer is preventable through regular screening – simply put, having a pap smear. The data suggests that the Canadian primary health care system is better able to provide the screening resources to patients. Women who avoid screening or have no opportunity to do so are at increased risk.

Cervical cancer commonly peaks within two age groups; 35 to 39 years and 60 to 64 years. Since the introduction of Pap tests over 40 years ago, the incidence of cervical cancer decreased from 45 to eight per 100,000 women. Indeed, there has been an increase in detection and incidence of precancerous changes and invasive tumours over this same period.

Death from cervical cancer decreased from a rate of 11 per 100,000 in 1951 to 2.39 per 100,000 in 1995. The rate of decline in incidence and mortality was similar for all age groups. Women over 65 have the highest incidence and mortality rates.

Early detection improves survival; 92 percent of women survive cervical cancer that has not spread or metastasized while only 10 percent with metastatic disease live for five years.

Unlike other cancers, women have the means to minimize their risk of cervical cancer. Indeed other than low socioeconomic status and increasing age, most risk factors fall under individual lifestyle choices. These modifiable risk factors include early age at first intercourse, greater number of sexual partners, infection with human papilloma virus (HPV) and smoking.

The virus that causes genital warts, HPV, also infects the cervix. A majority of women with cervical cancer and precancerous changes have HPV infection. In the United States, 20 percent of teenagers and 40 percent of women 20 to 29 years of age harbour HPV. Canadian rates are similar.

It can take years for the infection to cause cancer. HPV represents a class of about 50 to 60 viruses (subtypes). Only some of these subtypes cause cancer. Many women with HPV infection do not develop malignancies. Some precancerous changes spontaneously improve. Careful monitoring of these changes is mandatory.

HPV infection alone is not enough to cause cancer in some situations. One U.S. study of 296 women compared nonsmoking women without HPV (the control group) to three other groups: smokers, HPV infection alone and both smoking and HPV infection. The relative risk of pre-invasive cancer was two, 15 and 66 times more than the control group respectively.

This significant relationship persisted after adjusting for age and number of sexual partners. The longer someone smokes the greater the risk. Breakdown products of cigarette smoke have been found to concentrate in cervical mucous. The evidence implicates cigarette smoking as a co-conspirator with HPV with direct cancer-causing (carcinogenic) effects on the cervix.

Condoms are not foolproof protection from HPV because genital warts are not restricted to the genitalia. They can spread to the scrotum, anus and pubic areas. Skin to skin contact will pass the virus from one person to another. Treatment for HPV exists but early detection and treatment can reduce the duration, cost and complexity of therapy.

Treatment of cervical cancer depends on the patient’s age, their overall health, the desire to have children, the stage of the disease and size of the tumour. Treatment of advanced disease usually requires invasive surgery and radiation therapy.

Primary prevention is the best means of controlling this disease. This includes the sexual history of a new partner, screening of sexually transmitted infections (STIs) prior to any sexual activity, smoking cessation, being vigilant and delaying the onset of sexual intercourse.

The Pap test is the best means to date to screen for cervical cancer. Many women come into the office resigning themselves to this examination often with gender specific comments about their boyfriends and husbands best left to one’s imagination. Men, you don’t have a clue! Despite the compromising yet painless examination, it saves lives.

The Canadian Task Force on the Periodic Health Examination recommends annual screening with the Pap smear after initiation of sexual activity. A Pap test should be done after intercourse with a new partner. Women in long-term monogamous relationships having had two previous normal annual Pap smears can be screened every three years until age 69. Although the bane of many women, the cost of avoidance is too high.

OHIP hinders therapy for uterine bleeding

Dr. Barry Dworkin — Tue, 13 Aug 2002 20:58:57 +0000

Originally published in The Ottawa Citizen August 13, 2002

Original Title: Only Women Bleed

Dysfunctional Uterine Bleeding (DUB) is the leading cause of low blood iron and red blood cell levels (iron-deficiency anemia), causes painful menstrual cramps (dysmennorhea) and has great impact on work, social, home and sex life. DUB is defined as abnormal bleeding from within the uterus that is not caused by any pelvic diseases such as cancers, infections, general medical disorders, noncancerous growths, anatomic abnormalities such as fibroids or abnormal hormonal conditions. It is most commonly seen at either end of a woman’s reproductive years.

The diagnosis of DUB is one of exclusion once all other possible causes are eliminated using specific blood tests, ultrasounds, biopsy of the uterine lining (endometrium) and hysteroscopy (a fibreoptic camera that peers inside the uterus). The key hormones that influence the endometrium are estrogen and progesterone. Conventional treatments focus on controlling their effect upon the uterus in order to reduce bleeding.

Once DUB is confirmed, various treatment regimens are available. Nonsteroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen (Advil, Motrin), Naproxen (Naprosyn, Anaprox) alone can reduce bleeding by about 30 percent. Cyklokapron reduces blood loss by a different mechanism.

Birth control pills can reduce flow by as much as 50 percent but cannot be used for smokers over age 35 because of the increased risk of developing blood clots. These women may benefit from Depo-Provera, a progesterone only injection given every 12 weeks. Intrauterine devices (IUDs) impregnated with progesterone can reduce blood flow by up to 97 percent.

The success rate of medical therapy is about 50 to 60 percent. Treatments can last years right up until menopause and have side effects in 40 percent of the time. In can be an expensive long-term proposition in terms of time and money requiring numerous visits to the physician’s office for monitoring.

Surgical options are the next step if medical therapy fails.

Surgical Endometrial Ablation (SEA) is highly skill dependent. Few gynecologists perform this procedure. Using a fibreoptic scope the surgeon removes the entire endometrial layer. Complications include hemorrhage, infection, perforation of the uterus and heart failure due to the amount of fluids used during the procedure.

The final option is hysterectomy with all its inherent post-operative, physical and psychological complications. These last two procedures are quite a drastic approach to the problem. Granted for some this may be the only option but reside in the last-resort category.

There is another procedure that could prevent the need for surgery. Thermal Endometrial Ablation using Uterine Balloon Therapy (UBT) works by applying heat directly against the endometrium.

The procedure is similar to an IUD insertion. A soft inflatable balloon attached to a thin catheter is inserted into the uterus. It is then filled with up to 30 millilitres (one ounce) of water. The water is heated to 87 °C and evenly distributes the heat within the uterine cavity. It takes 8 minutes and is done under local anesthesia. To date there have not been any intra-operative complications. Within seven to ten days the endometrium will slough off resulting in a small period. Like SEA, it is 80 to 90 percent effective after 6 months but without the associated complications. Women can usually return to work the next day. Most will have a pinkish and watery vaginal discharge for two to four weeks. UBT is safe, effective, inexpensive over the long term and restores quality of life with minimal discomfort.

UBT is not an option for women who want to have children. Pregnancies can be dangerous for both the fetus and mother after UBT.

Sonohysterography or Saline Infusion Sonography (SIS) is an essential specialized ultrasound that reveals the complete contours of the uterine cavity. The results of the SIS are superior to conventional ultrasounds in the decision making for UBT. The results determine if UBT can be performed safely. It is advisable to perform SIS prior to offering UBT.

However SIS is no longer an insured service. OHIP states that the existing billing codes were never meant for SIS. Until there is a code approved by the tariff committee for this procedure, they will no longer reimburse the clinic or physicians for it. So now the Ottawa General OB/GYN ultrasound department and the Civic campus no longer provide this service.

The Bank Street Ultrasound Centre will provide SIS for a fee. This fee has been set by the Ontario Radiology Society at $300 to cover the cost of the scan, consulting fee, and the equipment.

UBT is available only at the Ottawa Hospital, General campus by a number of gynecologists under general anesthesia. Drs. Guy d’Anjou and Douglas Black use local anesthesia in about 50 percent of selected patients. But it cannot be done as safely since OHIP will not allow SIS.

Drs. d’Anjou and Black hope to open a Menorrhagia clinic at the newly created Riverside Hospital Woman’s Centre. It is their hope that SIS can be incorporated into the Centre. People should not have to suffer because of bureaucratic roadblocks.