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Adam S. Levine, M.D. recently finished his fellowship in reproductive endocrinology and infertility within the department of gynecology and obstetrics at the Johns Hopkins University School of Medicine. His areas of expertise include reproductive endocrinology, infertility, assisted reproductive technology, reproductive surgery, pediatric and adolescent gynecology, and menopause.

 

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Q:   My wife has an enlarged uterus. She has been having cramping and bleeding. On the recommendation of her doctors, she tried taking birth control pills, but they gave her extreme headaches. The doctors are now recommending a hysterectomy. Are there any alternatives?	A:   The two most common causes of an enlarged uterus are: uterine fibroid tumors, also known as myomas, fibroids or leiomyomas; and adenomyosis, a condition where the lining of the uterus (endometrium) grows into the muscle of the uterus. In either case, a woman may have an increase in bleeding or cramping with menses. One common treatment is to use oral contraceptives to regulate menses, resulting in a decrease in bleeding and cramping. However, there are a variety of medical and surgical therapies available to treat either fibroids or adenomyosis.    Medical management is possible with non-steroidal anti-inflammatory preparations such as ibuprofen or naproxen. These medications will significantly decrease cramping and may also decrease menstrual blood loss. Hormonal treatment is also possible. In addition to oral contraceptives, gonadotropin agonists such as Lupron, Zoladex or Synarel cause a temporary chemical menopause. This chemical menopause may stop further uterine growth and ultimately result in a decrease in size of the uterus. However, use of these medications is temporary and growth may resume following discontinuation. Surgical management is possible for fibroids because they occupy specific areas that can be removed. Surgery for adenomyosis is not possible, because it does not occupy a discrete location that can be removed. Hysterectomy (removal of the uterus) may be another option.    The most important part of any therapy is deciding t on the desired outcome. In any case, consultation with a gynecologist is necessary to evaluate an enlarged uterus. The treatment options and management plan should be carefully discussed.
Q:   I can touch my own cervix; it seems to have dropped after childbirth. I believe this is called a prolapsed uterus. What is involved in fixing it, and would it be better to have a second child before undergoing this procedure?	A:   The cervix is the connection or opening between the vagina and the uterus, and is normally suspended inside the vagina. A prolapse occurs when the connections between the vagina, cervix and uterus and the pelvic floor become weakened or break. This causes the cervix and uterus to "fall." In severe cases, the cervix or uterus may prolapse entirely through the labia. Other types of prolapse occur when the connections between the bladder or rectum and the pelvic floor become weakened or break. They respectively result in a cystocele (bladder protruding into the anterior part of the vagina) or rectocele (rectum protruding into the posterior part of the vagina).    There are two basic methods of correcting a prolapse. The first is non-surgical and involves using a pessary. A pessary is a device that is placed into the vagina to physically hold the cervix and uterus in place. In addition to a pessary, women usually will try to strengthen the pelvic floor with Kegel exercises. The second methods are surgical. Theoretically, since pregnancy and delivery may cause pelvic floor weakening, it would be reasonable to defer surgical correction until after childbearing is complete. Although some women can normally feel their cervix, it is reasonable to seek a gynecologic evaluation to assess the degree of prolapse and need for correction.
Q:   I have been diagnosed with an ovarian cyst (3.9mm) and will be going back for another examination next week. My doctor told me I would need to be put on depo-provera (for an unspecified time) if the cyst is still there. Following that treatment, if the cyst still does not go away, I might need a laparoscopy to remove it. Is depo-provera as common a treatment as birth control pills? I'm concerned about the side effects of depo-provera.	A:   A major concern of most women and their physicians is the early diagnosis of ovarian cancer. Unfortunately, there is no test (blood, x-ray, ultrasound) that will accurately detect ovarian cancer in its earliest stages. Since cancer is associated with ovarian masses and usually large complex ovarian cysts, many patients and their physicians are concerned about any ovarian cysts. However, ovaries in reproductive-age women (after puberty and before menopause) normally produce cysts. These cysts are simple; that is, they have a single thin wall and appear on ultrasound to be filled with fluid. They may also be as large as 20 to 22 mm. These cysts are also called "follicles" and represent normally maturing oocytes (eggs) prior to ovulation.    When a woman has an ovarian cyst, there are several acceptable treatment strategies. Depending on its appearance and the results of lab tests (e.g., blood tests) and the woman's symptoms (pain, bleeding, etc.), an ovarian cyst in a reproductive-age woman may be monitored or observed without treatment for between six and eight weeks. There is no evidence that any treatment (oral contraceptives, depo-provera, etc.) will reduce an existing ovarian cyst. Again, depending on the cyst's appearance and the results of lab tests and symptoms (pain, bleeding, etc.), an ovarian cyst in a pre-pubertal girl or a post-menopausal woman may also be observed without treatment for several weeks.    In many women, a persistent ovarian cyst may be an indication for surgical intervention. The surgical method that is used, whether laparoscopy (a telescope through the navel) or laparotomy (regular surgical incision), depends on the individual situation and is best discussed with an experienced gynecologic surgeon.    Depo-provera (manufactured by Upjohn Pharmaceuticals) is a synthetic hormone based on naturally-occurring progesterone and is administered as an injection into a muscle. Depo-provera's major side effects with short-term use are temporary discomfort at the injection site and irregular menses and spotting. (Some women do not have menses on depo-provera.) Women using depo-provera over a longer period of time (six to 12 plus months) are more likely to stop having menses and to gain a small amount of weight (2 to 4 kilograms). The major hesitation some women have to using depo-provera is its association to breast cancer in female beagles. Several large international studies do not support this association in humans.
Q:   I would like to know more about endometriosis. I have had surgery and a large mass removed. I then spent three months going through pseudo menopause. Now I still have it. Are there any new developments for assisting in a cure? I want to have children and don't want this to inhibit me or become a problem if and when I do get pregnant. Also, if a mother has endometriosis, is her daughter also likely to have it?	A:   Endometriosis is a condition where the lining of the uterus (endometrium) grows outside of the uterus. How and why endometriosis occurs is controversial. One possibility is that some of the menstrual blood and tissue exits the uterus through the fallopian tubes. This tissue can attach to the surface of the other pelvic organs (colon, bladder, ovaries, etc.) and grow. This endometrial tissue outside of the uterus is similar to the normal endometrial lining in that it is hormonally sensitive and grows and bleeds in cyclic fashion. Over time, a pelvic mass may develop if this endometrial tissue grows into the ovary and bleeds. The blood is trapped inside the ovary and forms a cyst called an endometrioma.    Endometriosis may be more common in certain families. It is most common in women that have never been pregnant. A suspicion that endometriosis exists may be based on a patient's history which commonly includes intermittent, chronic pelvic pain. Endometriosis is diagnosed by laparoscopy (camera and telescope through the navel). Gynecologic surgeons will commonly treat endometriosis when it is diagnosed. They may elect to remove the endometriosis or endometrioma by surgical excision or ablate it with electricity, lasers, or heat. In some cases, the endometriosis may be so severe that a major surgical excision will need to be made (laparotomy) to treat it. Women with severe endometriosis that have not responded to surgical or medical treatment and who have completed childbearing may elect to undergo a hysterectomy with removal of the ovaries for definitive management.    After diagnosis, there are a number of treatments available. Oral contraceptives decrease hormonal fluctuations during the menstrual cycle. They may be used in the traditional fashion with pill-free intervals, or taken continuously (no pill free interval). Oral contraceptives decrease the growth and bleeding of the endometriosis. Gonadotropin agonists such as Lupron, Zoladex, or Synarel cause a temporary chemical menopause. This chemical menopause will decrease or stop the growth and bleeding of endometriosis tissue. However, use of these medications is temporary and endometriosis growth and bleeding will probably resume following their discontinuation. In addition, there are some reports where gonadotropin agonists are being used over extended periods in conjunction with hormone replacement therapy. Endometriosis may also be treated with other hormonal therapies.    Endometriosis is a chronic condition and unfortunately there is no way to completely remove all of it. However, although women with endometriosis are more likely to experience difficulty becoming pregnant as compared to women without endometriosis, once a pregnancy has been completed, the endometriosis is not likely to reoccur.
Q:   What else can be done to shrink uterine fibroids, other than undergoing a hysterectomy or receiving injections of Lupron?	A:   Uterine fibroid tumors, also known as myomas or leiomyomas, are usually benign growths of muscle cells that make up the uterus. They may cause the uterus to enlarge and can also be a source of pain, increased menstrual cramping and bleeding or irregular menstrual bleeding. Fibroids grow in response to the naturally-occurring female hormonal environment. During menopause, many fibroids will stop growing and may decrease in size.    There are a variety of medical and surgical therapies currently available to treat fibroids. Medical therapy of uterine fibroids includes several currently-available medications and pharmaceutical products. Non-steroidal anti-inflammatory preparations--such as ibuprofen or naproxen--can significantly decrease cramping and may also decrease menstrual blood loss. Hormonal treatment of fibroids is controversial. Low-dose oral contraceptives decrease hormonal fluctuations during the menstrual cycle, and this may decrease their stimulatory effect on fibroid growth. Gonadotropin agonists such as Lupron, Zoladex or Synarel cause a temporary chemical menopause. This chemical menopause may stop fibroid growth and ultimately result in their shrinkage. However, use of these medications is temporary, and fibroids commonly stop shrinking and may resume growth following use.    Surgical management is more definitive than medical management and may be tailored to individual patient preference. There are two different surgical approaches. One is by abdominal incision, and the second is by laparoscopy (camera with telescope through the navel). If an abdominal incision is chosen, the fibroid(s) may be removed (myomectomy), or the patient may undergo a hysterectomy (removal of the uterus). If a laparoscopic approach is chosen, the fibroid(s) may be removed or destroyed by laser, freezing or application of electrical current.    The most important part of any therapy is deciding on the desired outcome. In this case, the question that should be addressed is why it is necessary to reduce the fibroid size. Aside from hysterectomy and Lupron, another gonadotropin agonist or a myomectomy may be effective in reducing total fibroid volume.
Q:    What is the treatment for uterine fibroid tumors and the use of lupron? I have severe pain mostly with menstrual periods. I have a fibroid, verified on ultrasound.	A:    Uterine fibroid tumors, also known as myomas or leiomyomas, are virtually always benign growths of the muscle cells that make up the uterus. They generally cause the uterus to enlarge and may be a source of pain, increased menstrual cramping and bleeding, or irregular menstrual bleeding. Fibroids are thought to grow in response to the naturally occurring female hormonal environment. This suggests that many fibroids will stop growing and may decrease in size during menopause. Fibroids may be detected during a gynecologic examination. Infrequently, an ultrasound or x-ray may be used to assist with their diagnosis. In many cases, women will have more than one fibroid. There are a variety of medical and surgical therapies currently available to treat fibroids.     Surgical management is more definitive than medical management and may be tailored to individual patient preference. There are two different types of surgical approach. One is by abdominal incision and the second is by laparoscopy (camera with telescope through the navel). If an abdominal incision is chosen, the fibroid(s) may be removed (myomectomy) or the patient may undergo a hysterectomy (removal of the uterus). If a laparoscopic approach is chosen, the fibroid(s) may be removed or destroyed by laser, freezing, or application of electrical current.     Medical therapy of uterine fibroids with several currently available pharmaceutical products is possible. Non-steroidal anti-inflammatory preparations such as ibuprofen or naproxen will significantly decrease cramping and may also decrease menstrual blood loss. Hormonal treatment of fibroids is controversial. Low-dose oral contraceptives decrease hormonal fluctuations during the menstrual cycle and this may decrease their stimulatory effect on fibroid growth. Gonadotropin agonists such as Lupron, Zoladex, or Synarel cause a temporary chemical menopause. This chemical menopause may stop fibroid growth and ultimately result in their shrinkage. However, use of these medications is temporary and fibroids commonly stop shrinking and may resume growth following use.     An important consideration prior to beginning any medical or surgical intervention is to determine what the long and short-term goals of the treatment are. You state that pain is worse with menses. A physician should evaluate severe pain. A major challenge in evaluating pain is determining its cause. The fact that there is pain in the presence of a fibroid does not necessarily mean that the fibroid is causing the pain.