Immediately after your surgery, you may have a catheter (a tube) that drains urine from the bladder into a bag, and a pack in the vagina to prevent bleeding. Your doctor will specify how long these will need to stay in place, usually between 8 to 24 hours.

You may experience some pain or discomfort in the groin, vagina, and lower abdomen after surgery. If you have had a sacrospinous suspension (vaginal vault or uterine) you may also experience a sharp or aching pain deep in your buttock(s). Most pain or discomfort settles within a week or two, but it can sometimes be present for several weeks. While in the hospital you will be prescribed regular pain relief to keep you comfortable. On discharge from the hospital, painkillers will be prescribed though often over-the-counter painkillers should be sufficient. Pain relief in the early post-operative period is best taken at regular intervals; don’t wait for pain to become severe before taking medication. Staying on top of any pain will help to keep you mobile and to recover more quickly. If you are experiencing severe pain that doesn’t settle after pain killers contact your doctor.

The risk of developing a deep vein thrombosis (clots in the veins in the legs) is increased following surgery. To minimize this risk your doctor may prescribe compression stockings and a daily blood thinning injection. While you are in bed, try to do simple exercises such as moving your ankles briskly in a circular motion, bending and straightening your legs a few times each hour. Avoid crossing your legs. You are advised to mobilise (under supervision) as soon as possible after the operation. Sometimes extra preventive measures may be advised, especially when your health status increases the risk of blood clot development. Your doctor will discuss this with you if necessary.

After a vaginal repair you may notice that at first your urine flow is slowed and it takes longer than normal to empty your bladder. About 5 to 10% of women have difficulty emptying their bladder fully after surgery; a catheter may then be needed until swelling settles and the bladder returns to its normal function (usually after 1-2 weeks).

Constipation is a common problem following surgery. Before and after your surgical procedure eat plenty of fruit and fiber and drink plenty of fluids to keep your stool soft. Following surgery stool softeners (laxatives) are often prescribed to help prevent constipation. Take these on a regular basis when you first go home. It is important to avoid excessive straining to pass a bowel motion as this can put pressure onto the stitches in the vagina. Some women experience burning or shooting pains in the rectum after surgery. This usually settles within a few days after surgery.

It is normal to have some bleeding followed by a creamy white discharge that may last for up to 6 weeks as stitches in the vagina dissolve. At first the blood loss may be bright red; later this usually changes to a darker reddish brown. The amount of bleeding can vary from day to day. If you experience heavy fresh red bleeding or clots requiring frequent pad changes, contact your doctor. Use pads, not tampons, for the first 6 weeks after surgery.

You will usually feel well enough for this the day after surgery. Showering is preferable to bathing in the first 6 weeks after surgery when vaginal stitches are still present.

Following surgery, you will feel more tired than usual. Therefore, make sure you take plenty of rest and listen to your body. Start by walking around the house and as you feel ready, increase your activity to include short daily walks. Walking is a good form of activity as it puts little strain on your surgical repair. Do not try to exercise to gain fitness, e.g. by jogging, power walking, aerobics classes, etc. for at least 6 weeks following surgery. It is safe to (re-)start pelvic floor exercises when you feel ready, usually 1 to 2 weeks after surgery. For more information on how to perform pelvic floor exercises, see the leaflet Pelvic Floor Exercises.

• Heavy lifting and strenuous activities. You should not be carrying anything more than 5-7 kilograms. Heavy lifting puts pressure on the surgical repair and this can increase the risk of having a recurrence of the prolapse.
• Carrying small children, heavy shopping, gardening and heavy housework such as vacuuming, lifting washing baskets, moving furniture etc
• Exercises with high impact such as aerobics, running, horse riding, gym training, and heavy lifting. These all put heavy forces on the pelvic floor.
• Try to stop smoking. It may delay wound healing and increases the risk of wound infection.

You can eat and drink as usual as soon as your appetite returns after the operation. Aim for a balanced diet to receive all the nutrients your body needs. It will be helpful to include foods with plenty of fibres such as muesli, prunes, and kiwi fruit and up to 2-2.5 liters of fluid intake a day to keep your bowels regular.

Everyone recovers at a different rate and this depends on several factors: your health and fitness state before operation, whether complications occurred, and the type of repair performed. It is important to listen to your body and take time to rest. Do not try to push yourself too hard. Over the course of 4-6 weeks your body will gradually heal, and your energy level will slowly rise to a normal level.

If you develop heavy or a foul smelling vaginal discharge or bleeding, burning or stinging on passing urine, increasing abdominal pains, vomiting, fever, painful swollen leg(s), shortness of breath or chest pain, seek medical advice..

You should not drive if you are taking sedative painkillers or are not confident that you could perform an emergency stop if needed. As a general guide, avoid driving for 1 to 2 weeks. If unsure, check with your doctor. Some insurance companies place restrictions on driving after surgery, so check your policy details.

This will depend on the type of work you do, the number of hours you work, and how you get to and from work. Your doctor can help you decide how much time you will need to take. Most patients will need between 2 and 6 weeks off work. It may be advisable to try to organise a shortened work week or light duties when you first return to work, especially if you are in a job that involves standing or heavy lifting.

It is advisable to refrain from sexual intercourse for 6 weeks after you have been discharged from the hospital. Intercourse may be a little uncomfortable to begin with so take things slowly and gently. Using a vaginal lubricant may be helpful if you feel dry. If intercourse remains uncomfortable after 3 or 4 months of regular trying seek advice from your doctor.

Prolapse is the loss of normal support of the vagina and/or uterus (womb). Prolapse of the uterus and/or vaginal walls is a common condition with up to 11% of women requiring surgery during their lifetime. Prolapse generally occurs due to damage to the supporting structures of the uterus or vagina. Weakening of the supports can occur during childbirth, following chronic heavy lifting or straining (e.g. with constipation), chronic cough, obesity, and as part of the ageing process. In some cases, there may be a genetic weakness of the supportive tissues.

Prolapse of the uterus can cause an uncomfortable bulging sensation, a feeling of fullness, or pressure in the vagina. In more advanced prolapse the cervix can extend beyond the entrance to the vagina.

This is a procedure in which the uterus is surgically removed through the vagina. The operation is frequently combined with prolapse repairs of the bladder and/or bowel. There are no abdominal or laparoscopic incisions.

A vaginal hysterectomy offers many benefits over abdominal or laparoscopic procedures. It offers overall fewer complications, shorter healing time, less pain, less scarring, a lower chance of infection, less risk of hernias, and faster return to activities. Also, a prolapsed uterus is easier to access via the vagina.

The operation is performed in a hospital setting and can be performed under general or spinal anesthesia (with or without sedation). A cut is made around the cervix. The surgeon then carefully pushes the bowel and bladder away from the uterus. The blood vessels supplying the uterus and surrounding tissue are then clamped and secured. After confirming there is no bleeding, the surgeon removes the uterus and closes the top of the vagina, now known as the vaginal vault.

Many surgeons will choose to add additional support stitches to the vaginal vault at the time of surgery – either to the uterosacral ligaments that support the uterus (this is called a uterosacral ligament suspension) or to support structures on the side of the uterus (this is called a sacrospinous ligament suspension or ileococcygeus suspension). Leaflets are available on both of these procedures for more information. These additional stitches help to reduce the risk of the vaginal vault prolapsing in the future. Your doctor can explain what he/she plans to do. The ovaries can be removed during a vaginal hysterectomy if needed.

You will be asked about your general health, past medical history and any medication that you are taking. Any necessary tests (for example blood tests, ECG, chest X –ray) will be arranged. You will also receive information about your admission, hospital stay, operation and pre- as well as post-operative care. Mention to your doctor if you are on blood thinning agents such as aspirin, as these can lead to an increased risk of bleeding and bruising during and after surgery. Your doctor may ask you to stop the blood thinning medications 7 to 10 days prior to surgery. Some surgeons recommend bowel preparation prior to surgery.

When you wake up you will have a drip (IV) to give you fluids and you may have a catheter in your bladder. You may have a vaginal pack to reduce the chance of bleeding. Generally, the pack, catheter, and drip are removed in the first 24 to 48 hours after surgery. In most cases you will be able to eat and drink almost immediately after surgery. Pain and anti-nausea medication are given when needed, either intravenously, by intramuscular injection, or pill.

Keeping mobile after surgery is important to reduce complications such as clots in the legs and breathing problems, including pneumonia. Walking and light household duties are fine; however heavy lifting (more than 10kgs/25lbs) is not advisable in the first 6 weeks post-operatively. It is normal to feel tired following surgery so make sure you schedule rest times in the first few weeks after surgery.

You can expect to stay in the hospital 1-3 days. It is normal to get a creamy/brownish or bloody discharge for 4 - 6 weeks after surgery. This is due to the presence of stitches in the vagina. As the stitches absorb, the discharge will gradually reduce.

85% of women having a vaginal hysterectomy for uterine prolapse are cured permanently. About 15% of women develop a further prolapse of the vaginal vault months or years after their first surgery. These figures may vary depending on the severity of your original prolapse.

With any operation there is always a risk of complications:

• Anaesthetic problems. With modern anaesthetics and monitoring equipment complications due to anaesthesia are very rare.
• Clots (embolism). After any pelvic surgery clots can form in the legs or lungs. This is a rare complication which is minimised by using support stockings and possibly blood-thinning agents post-operatively (if indicated).
• Severe blood loss and haematoma. The risk of blood loss requiring blood transfusion is small (0-10%) and will in part vary on what other surgery you are having. About 10% of women develop a small collection of blood at the vaginal vault (a haematoma). This usually drains spontaneously after 7 to 10 days. Occasionally it will require surgical drainage.
• Infections. Although antibiotics are given just before surgery and all attempts are made to keep surgery sterile, there is a small chance of developing a vaginal or pelvic infection. This will usually present with an unpleasant smelling vaginal discharge and/or fever.
• Urinary tract infection. 6-20% of women having vaginal surgery develop a urinary tract infection. The risk is highest if you have had a catheter. Symptoms include burning and stinging when passing urine and frequency. If you think you have an infection after surgery contact your doctor.
• Injury to adjacent organs. Up to 2% of vaginal hysterectomies are complicated by either damage to the bladder, the ureters, or rectum. A very rare complication is the occurrence of a vaginal fistula.
• Urinary retention. In the first few days after surgery, difficulty passing urine can occur in up to 10-15% of cases. You may need to have a catheter for a few days after surgery until you are able to easily pass urine.
• Urinary incontinence. Prior to surgery, it is possible to have had urinary incontinence which was “occult” or hidden by the prolapse. During surgery, the urethra (the tube which empties the bladder) becomes unkinked or unobstructed, resulting in urinary incontinence becoming obvious post- operatively. This can occur in 40-45% of cases.

You should be able to drive and be fit enough for light activities such as short walks within a few weeks of surgery. You are advised to avoid heavy lifting and sport for at least 6 weeks to allow the wounds to heal. It is usually advisable to plan to take 2 to 6 weeks off work, depending on the type of surgery you have had and the type of work you do. Sexual activity can usually be safely resumed after 6 weeks.

Prolapse of the uterus (womb) and/or vaginal walls is a common condition affecting up to 50% of women. Up to 11% of women require surgery for prolapse during their lifetime. Prolapse generally occurs due to weakness of the supporting structures of the uterus or vagina. Weakening of the supports can occur during childbirth, as a result of chronic heavy lifting or straining e.g. with constipation, chronic cough, obesity and as part of the ageing process. In some cases, there may be a genetic weakness of the supportive tissues.

Prolapse of the uterus can cause an uncomfortable dragging sensation or feeling of fullness in the vagina, complaints of frequent urination, difficulty emptying the bladder and urinary tract infections. In more advanced cases, the prolapse can extend beyond the entrance of the vagina.

A vaginal pessary is a removable device that is placed in your vagina to support the weakened and prolapsed walls of the vagina or uterus. Different types of pessary are available: ring pessary with or without support, gellhorn pessary and a cube pessary are the most commonly used types of pessaries. Some pessaries such as ring pessaries can safely remain in the vagina for several months without removal. Others, such as the cube pessaries, must be removed and cleaned on a daily basis. Most pessaries are made from silicone, a soft non-absorbant material that poses no threat to your health. After a while the outer surface of the pessary can discolor. This is normal and does not mean that a new pessary has to be placed.

Most pessaries are placed to improve symptoms of prolapse of the uterus and/or vaginal walls (see above). Sometimes your gynecologist will suggest a pessary to prevent or reduce urinary incontinence during exercise. Pessaries are most suitable if you wish to avoid or delay surgery, e.g. if your family is not yet complete or if you have medical problems that will make surgery a risk.

Pessaries are fitted by first performing a vaginal examination to assess the type of prolapse. Your doctor will also measure your vagina to decide on the best type of pessary for your individual case. When the pessary is too small it may fall out, either on its own or when passing urine or during a bowel motion. A pessary that is too large may give pressure symptoms and feel too uncomfortable. Sometimes it can take a few attempts to find the most suitable size and type of pessary.

A minor prolapse may be treated with physiotherapy, while more severe prolapses may require the use of a pessary or an operation.

Once the pessary is inserted and placed appropriately in the vagina, it needs to be changed and checked at regular intervals. Practices between doctors vary but most will suggest that a pessary is cleaned or changed and the vagina checked every 3-6 months. Some women using ring pessaries are able to remove, clean, and replace the pessary themselves, otherwise this can be done at their doctor’s office. For some pessaries, such as the cube pessaries, daily removal is needed and they are therefore less suitable for longer term use. The gellhorn pessary is often used for more serious degrees of prolapse and this type of pes- sary usually requires removal by a doctor or nurse.

• Bleeding/ulceration to the vaginal wall. Depending on the type and size of pessary there is a chance that ulcerated areas may develop in the vagina. In this case you may experience a pinkish or bloody discharge. Ulcerated areas usually heal easily simply by removing the pessary for a short time. If you notice a bloody discharge, make an appointment with your doctor.
• Pain or discomfort. You should not be able to feel a pessary if it is correctly placed. If you experience significant pain or discomfort the pessary may be too large or small and require replacement with a different size. Talk to your doctor if this happens.
• Discharge. Most women experience a small amount of whitish discharge. With a ring in place this discharge may increase a little, but it should not be colored or unpleasant smelling. Both of these symptoms may indicate a vaginal infection and/or ulceration. Many doctors prescribe the use of vaginal oestrogen cream to reduce the risk of ulceration. This can also result in an increased amount of creamy white discharge.

The pessary should give women a solution without limitations to daily activity. For instance, you should be able to do sports, cycle and walk longer distances.

If you have a ring pessary it is very possible to have intercourse with the ring in position. If you or your partner feel the ring with intercourse you can choose to remove the ring, replacing it again after intercourse. Other pessaries such as the doughnut, cube, or gellhorn pessaries largely fill the vagina and it is not possible to have sex while these pessaries are inserted. Make sure your doctor knows if you wish to be sexually active so that a suitable alternative pessary or other treatment can be planned.

After menopause the vaginal skin thins due to a lack of estrogen. This may make the vagina dry and also more prone to ulceration when a pessary is in place. Your doctor may prescribe vaginal oestrogen to improve the vaginal skin, making it healthier. Your doctor will discuss the possible indications for the use of oestrogens and the consequences of use. For more information on vaginal oestrogen treatment read our leaflet entitled Low-Dose Vaginal Oestrogen Therapy.

Stress Urinary Incontinence (SUI) is the involuntary leakage of urine during activities such as coughing, sneezing, lifting, laughing or exercising. SUI affects at least 10-20% of women, many of whom do not realise that there are simple, effective treatment options available.

SUI affects the quality of women’s lives in many ways. Incontinence may limit women’s social and personal relationships as well as limit physical activity.

As urine is produced and fills the bladder, the bladder (detrusor) muscle relaxes and stretches to accommodate the fluid. When the bladder is filled to a certain level, an urge to pass urine is felt, and when it is appropriate, the brain signals the detrusor muscle to contract and the urethral sphincter to relax, thus allowing urine to be passed. The bladder usually needs to be emptied about 5-7 times per day, and 1-2 times at night.

The urethra (tube that carries urine out of the body) and bladder are supported by the pelvic floor muscles, which contract during coughing, sneezing and exercise to prevent leakage. Weakness in the muscles or damage to the bladder neck support can result in leakage.

• Pregnancy and vaginal birth
• Obesity, chronic cough, chronic heavy lifting and constipation can cause an increase in abdominal pressure and aggravate stress incontinence
• Genetically inherited factors

Your physician will ask questions about activities which cause leakage and will normally examine you to see if there are any other relevant problems, such as prolapse. Women with stress incontinence may also have problems with urinary urge incontinence, or incontinence of faeces or gas. Do not feel embarrassed to mention these problems to your doctor.

• To help with diagnosis, your doctor may ask you to cough while you have a comfortably full bladder.
• You may be asked to fill in a frequency volume chart (bladder diary), recording how much you drink, as well as the number of times you pass urine and the volume passed each time. A record of the amount of leakage is also kept
• Your doctor may recommend urodynamic studies. Urodynamics investigate the bladder’s ability to fill and empty, and the mechanism or cause of the incontinence.
• An ultrasound scan may be used to determine how much urine is left in the bladder after it empties and can identify if there are any other causes for your symptoms.
• A urine test may be performed to look for a urinary tract infection
• Urodynamic Test

All these tests are designed to help plan the best treatment for each individual.

Your physician will advise you on the best options for you, but initially conservative treatment may be recommended.

• General lifestyle changes. Aim to drink enough to pass urine 4 to 6 times per day (usually about 1.5-2 liters; half a gallon).Maintaining weight within a healthy range has been shown to reduce the severity of SUI problems. Avoiding causes of constipation and cutting out smoking can also help.
• Pelvic floor exercises. Pelvic Floor exercises (PFE) can be a very effective way of improving symptoms of SUI. Up to 75% of women show an improvement in leakage after PFE training. Like all training, the benefits of pelvic floor exercises are maximised if practice is carried out regularly over a period of time. Maximum benefit usually occurs after 3 to 6 months of regular exercising. You may be referred to a therapist who specialises in teaching PFEs to supervise this.If you also have a problem with urge urinary incontinence,your doctor may also advise bladder training exercise.
• Continence devices. Continence devices are available which fit in the vagina and help control leakage. These can be inserted prior to exercise or in the case of a vaginal pessary, worn continuously. Some women find inserting a large tampon prior to exercise may prevent or reduce leakage. These types of devices are most suitable for women with minor degrees of urinary incontinence or who are waiting definitive surgical treatment.

Many women experience bladder problems at some time in their lives. Three of the most common problems are frequency, urgency, and urge leakage. Frequency means going to the toilet more than 7 times a day. If you get up to go to the toilet more than once at night this is called nocturia. Urgency is the sudden and overwhelming feeling that you need to go to the toilet right now, and if you leak when you feel like this, it is called urge leakage

Bladder training is about getting rid of bad habits, learning good habits, and putting you back in control rather than your bladder controlling you and your life.

Research has shown that many women find bladder training reduces frequency, urgency, and urge leakage. Bladder training programs help you to increase the time between visits to the toilet, help you increase the amount your bladder will hold, and help you to control the feelings of urgency when the bladder contracts unnecessarily. Bladder training is about helping yourself to regain bladder control

Part of a bladder training program is learning to understand the messages that your bladder is sending you, which messages you need to listen to, and which messages you can ignore. A bladder training program should also help you to recognize when your bladder is full and when it isn’t.

Your bladder may have taken many weeks, months, or years establishing its bad habits, so you will not regain your bladder control instantly. It will take time, commitment, and patience to train your bladder into good habits. Be encouraged; most people notice some improvement within 2 weeks, although it may take 3 months or more to regain bladder control.

Sometimes there are other changes you can make that will help to improve bladder control. If you are overweight, have a problem that makes you cough a lot (e.g. asthma, bronchitis) or suffer from constipation, you should discuss this with your doctor, physiotherapist or continence advisor, as all these things can make urinary leakage worse. Some medications make it more difficult to control the bladder, and you should check with your doctor if you have any worries about this.

• Drink normally, at least 6-8 cups (1000ml - 1500ml) of fluid per day unless advised otherwise by your doctor. Don’t stop drinking because you think it will stop your leaking. If you drink too little, the urine becomes very concentrated. This irritates the bladder and makes it want to empty more often even when there is very little in it. A lack of fluids can also lead to urinary tract infections.
• Don’t drink all your fluids at once. Space your fluid intake out during the day. If you drink a lot at once, you can expect the need to go to the toilet urgently not too long afterwards.
• Some drinks seem to irritate the bladder and make you want to go to the toilet more often. Usually these are alcohol and drinks with caffeine in them such as coffee, tea, cola, chocolate drinks, and carbonated energy drinks. Try to reduce caffeinated drinks to 1 or 2 cups a day
• Avoid drinking within two hours of going to bed, as this increases your chances of getting up at night.

• Check your bladder diary (see sample below or download a blank bladder diary at www.YourPelvicFloor.org). How often are you going to the toilet during the day? If the visits are less than 2-3 hours apart, you need to try to increase the time between visits to the toilet. For example, if you are going every hour, set your target at an hour and 15 minutes. If you get the feeling of urgency before your time is up, try some of the ideas in the next section to control this feeling and make the bladder wait.
• If you can hold on for your target time and can do this for 3 or 4 days in a row, increase the time again. Gradually increase the time between visits to the toilet until you are going every 2-3 hours during the day.
• Try to cut down the visits to the toilet that you make ‘just in case.’ For example, ask yourself if you really do need to go every time you leave the house. If you only went 20 minutes ago, perhaps you don’t. A normal bladder comfortably holds 400mls, which is nearly 2 cups.

Try all of these ideas to control the urgency and make the bladder wait. See which ideas work best for you and then use them when you need to.

• Tighten your pelvic floor muscles as hard as you can and hold on for as long as you can. Keep doing this until the feeling of urgency goes away or is under control. Contracting the pelvic floor muscles helps to squeeze the urethra (tube from the bladder) shut and prevent leakage.
• Tighten your pelvic floor muscles quickly and as hard as you can, then let go. Repeat this several times in a row. Some women find that several contractions in a row work better than trying to hold on to a contraction for a long time.
• Put firm pressure on the perineum (crotch area). You can do this by crossing your legs or sitting down on a firm surface. This also sends a message to the bladder via the nerves that the outlet from the bladder is closed so it should wait before it tries to empty.
• Distract your mind as best you can. For example, some people start to count backwards from 100, but any form of mental distraction or relaxation is good.
• Change your position if this decreases the feeling of urgency. Some people find that leaning forward a little helps.
• Stay still when you get an urgent bladder contraction and control the urge. You will struggle to hold on and stay in control if you rush to the toilet.
• Try not to jiggle up and down on the spot. Movement jolts the bladder and may make the problem worse.

Bladder training (and pelvic floor muscle training, if appropriate) helps 1 out of every 2 to 3 women with urge leakage. Remember, when you have successfully trained your bladder into good habits, you need to practice these habits for the rest of your life.

Nocturia is a condition which causes you to awaken many times (more than 2 times) during the night to urinate. This leads to sleep deprivation. Nocturia is more common as we age.

Nocturia is generally caused by polyuria (an excessive or abnormally large production of urine), low nighttime bladder capacity (not being able to hold enough in the bladder at night), or a combination of these.

Polyuria may be caused by:

• High fluid intake, especially in the evening.
• Untreated or poorly controlled diabetes. High blood sugar can make you thirsty and the resulting high fluid intake leads to polyuria.
• Congestive heart failure – a condition in which the heart does not pump blood through the body efficiently – can result in a large amount of fluid gathering in the legs and a decrease in blood flow to the kidneys, which is the cause of urine production during the day.
• Swelling of the legs as a result of fluid accumulation during the day. Once you lay down at night, the fluid shifts to the kidneys where urine is produced.
• Medications such as “water pills,” some heart medicines, demeclocycline, lithium, methoxyflurane, phenytoin, propoxyphene, and high dose Vitamin D.

Low nighttime bladder capacity may be caused by:

• Sleeping disorders which interrupt sleep, leading to more frequent bladder emptying during the night. This, over time, reduces the bladder’s ability to hold urine.
• Bladder obstruction (blockage) from spasm of the urethra, urethral stricture (partial blockage of the tube that empties the bladder), or a mass/tumor on the bladder or another pelvic organ.
• Bladder spasm/overactivity (as in overactive bladder, with or without urge urinary incontinence – see www. yourpelvicfloor.org/conditions/overactive-bladder).
• Bladder infection, recurrent infection, or inflammation that causes the bladder wall to stiffen, often with shrinkage, irritation, and spasm. Eventually the bladder is unable to hold as much urine at night.
• Interstitial cystitis (Painful Bladder Syndrome – see www.yourpelvicfloor.org/conditions/interstitial- cystitis), which can cause bladder pain, in turn leading to the need to go to the toilet with greater frequency at night, just as it does during the day.
• Neurogenic bladder disorder, in which the nerve communicates abnormally to the bladder, causing abnormal filling and emptying.

Your healthcare provider will take a careful history, which will include your medical history and any medications you are taking. In addition to doing a physical examination, your provider will likely order a urinalysis (urine test) and ask you to complete a bladder diary.

Bladder Diary

A bladder diary (see www.yourpelvicfloor.org/conditions/bladder-diary-2) is a record of the fluids you drink, including when and how much, kept across a period of 2-3 days. You will also record when you urinate, how much you urinate, and if you experienced any urgency and/or urine leakage. This information helps your healthcare provider determine the possible cause(s) of your nocturia.

When you meet with your healthcare provider, you should be prepared to provide the following information:

• Approximate time the condition began
• Approximate number of times you urinate per night
• Amount you urinate at night (small, medium, large)
• Any recent changes in your urination habits
• Any diet changes (consumption of soda, spices, fluids, etc.
• Any medications you are taking, including the dose and time of day you take each medication, or recent changes in medications you are taking
• Amount of alcohol and/or caffeinated beverages you consume and when
• Average number of hours of sleep you get per night (currently) and any recent changes in sleep habits

Treatment is dependent on the cause of the nocturia. If the cause is based on a disease, then the disease is treated. Otherwise, treatments fall into three categories: conservative approaches, medications, or surgical/procedural options. Conservative treatments are typically tried first.

Conservative Approaches:

• Restricting fluids, including caffeine and alcohol, especially after 4pm
• Taking “water pills” – preferably in the morning, but at least 6 hours before bedtime
• Elevating your legs above your chest, for example by using a recliner
• Wearing compression stockings

Medications:

• Desmopressin is the most commonly used medication for nocturia. It works by reducing the amount of urine produced at night. Most patients have no side effects, although headache or dizziness may occur. This medication requires regular blood tests to ensure you do not lose too much salt. Patients suffering from congestive heart failure cannot use this drug.
• Anticholinergic medications may be used to decrease bladder spasm, which tends to be present in most people experiencing nocturia. These medications will also decrease bladder spasm during the day. Side effects may include dry mouth or constipation. Sometimes anticholinergics are not recommended due to an increased possibility of confusion or falls in individuals over 65 years of age.
• Beta 3-adrenergic receptor agonists may relax the bladder muscle and increase bladder capacity with few side effects. It may be a first choice for elderly patients.
• Diuretic medications regulate urine production. These should be taken in the morning to cause maximum excretion of urine during the day and to decrease the amount urinated at night. Side effects are rare but may include headache and dizziness. Blood tests are recommended, as potassium supplements may be needed.

Surgical/Procedural Options:

• Bladder instillations (placing medications directly inside the bladder) can be done in the office. This is typically performed weekly for up to 6 weeks, based on symptoms.
• Injecting botulinum toxin A into the bladder wall through a tiny scope to relax the bladder muscle (outpatient procedure), if the cause of nocturia is non-responsive overactive bladder (see www.yourpelvicfloor. org/conditions/botulinum-toxin-a-bota-for-overactive-bladder-and-neurogenic-detrusor-overactivity).
• Placing a pacemaker-like device called a sacral neuromodulator to tell the bladder when and when not to contract, if the cause of nocturia is non-responsive overactive bladder.
• Bladder augmentation (adding on to the bladder) in very rare/special cases.
• Urinary diversion - a surgical procedure that reroutes urine through a new “bladder” usually made from your bowel.

This is a syndrome in which one has nocturia due to a hormonal disorder. Antidiuretic hormone (ADH) normally increases at night to prevent increased urination. Individuals with NPS have low levels or absent levels of ADH at night, which causes increased urination at night. The 24-hour urine output is normal. The treatment is replacement of ADH at night.

An overactive bladder is a common problem. It can cause you a sudden, urgent desire to pass urine during the day as well as at night, and can sometimes cause you to leak some urine before you reach the toilet.

Urgency and urge-incontinence: Sudden and intense uncontrollable sensation to pass urine, which may leak

Frequency: Going to the toilet more than seven times a day

Nocturia: Going to the toilet more than once a night

Coital incontinence: Leaking at time of orgasm

The bladder is like a balloon. Normally the bladder muscle is relaxed while the bladder fills up gradually. Urine is kept inside the bladder by a valve-like mechanism. The valve stays closed until you feel the need to empty it, and have reached a toilet. The valve mechanism is assisted by the pelvic floor muscles below the bladder, which contract when you cough or sneeze. As the bladder fills up, you become aware of the need to pass urine, but are able to hold on. Once you decide to empty your bladder, the brain signals the muscles to contract and empty the bladder. The bladder usually needs to be emptied less than seven times during the day, and once at night.

• Urinary tract infection
• Conditions such as MS, which affect the nervous system
• Previous surgery for stress-incontinence, causing obstruction
• The number and type of caffeinated drinks and fizzy drinks
• Idiopathic (unknown) causes

• Urinalysis, to exclude urinary tract infection
• Measuring residual urine via ultrasound machine, or small catheter
• Urodynamics: assessing the activity of the bladder muscle as it is filled with fluid

Changing general lifestyle

Reducing alcohol intake, fruit juices and fizzy drinks

Aim to drink 1.5 to 2.0 litres of water

Switching to herbal teas and decaffeinated drinks

Bladder retraining and physiotherapy

This aims to help you strengthen your pelvic floor muscle to hold more urine, by going to the toilet less. It involves gradually increasing the time between visits to the toilet. Start by delaying going to the toilet by 15 minutes, until you can reach two to three hours between visits. You can book yourself in for a consultation with the physiotherapist at the Shoalhaven District Memorial Hospital.

Magnetic chair

A non-invasive and successful way of treating the overactive bladder. It involved 20 minutes of sitting on a special chair twice a week for five weeks, then weekly for ten weeks and fortnightly thereafter. Women with hip replacements and pacemakers cannot use this treatment.

Medication

There are anticholinergic drugs such as Ditropan, Vesicare or Oxytrol. The side-effects can be dry mouth, dry eyes and constipation.

Botulinum toxin (known as Botox)

Botox injections into the bladder muscle wall. This treatment decreases the abnormal contractions of the bladder. However, it may also reduce the normal contractions, so that your bladder is not able to empty completely. A side-effect can be leakage.

Sacral nerve stimulation

This involves direct stimulation to the nerves that control your bladder function.

Urodynamics is the name given to a number of tests designed to show how your bladder functions. The main test is called cystometry, which measures your bladder’s ability to store and pass urine.

Urinary problems, especially incontinence, may affect women of any age. Problems such as these usually increase with age, pregnancy, childbirth, and the onset of menopause.

Your symptoms may include:

• Loss of urine while coughing, sneezing, laughing, or exercising
• Sudden and/or frequent need to pass urine
• Getting up at night frequently to pass urine
• Difficulty in emptying your bladder
• Recurrent bladder infections

Results from urodynamic tests allow your doctor to demonstrate the reason why you have the symptoms you have, and so offer you the best treatment for your problems.

Not everyone with bladder symptoms will need to have urodynamics. If simple conservative management such as altering your fluid intake, exercises and/or medicine fails, then urodynamics is the best way that your bladder function can be properly measured and treatment tailored to your particular problem.

You will normally be asked to attend for the tests with a comfortably full bladder, so if possible, do not pass urine in the hour prior to your appointment. The procedure takes approximately 30 minutes and does not require any dieting or fasting. No anesthetic is required. On the day of the test, wear separates (i.e. a skirt or trousers and shirt), as you will need to remove your lower clothing and change into a gown.

There are several slightly different ways that urodynamics can be performed, but the principles are the same for all.

• You may first be asked to do a series of exercises with a full bladder to see how bad your leakage is. This is called a pad test. Don’t worry – you will not be expected to do anything which you are not normally able to do easily.
• You will then be asked to pass urine into a special toilet to measure how quickly your bladder is able to empty. You may have a bladder scan immediately after you have passed urine to assess how well your bladder has emptied.
• Following this, a small plastic tube called a catheter will be inserted into your bladder so it can be filled with fluid. Two fine soft catheters (sensors) will also be inserted, one of them into the bladder and the other into the vagina or rectum. These lines will record pressures measured in your bladder and abdomen.
• During the procedure you will be asked questions about the sensations in your bladder. You will also be asked to do some of the things which might trigger the problem you have (e.g. cough, strain, jog, stand up, or listen to the sound of running water). Let the person doing the test know when your bladder feels full.
• Finally, you will be asked to empty your bladder again, with the two fine sensors still in place. The sensors are then removed and the procedure is complete, and you can get dressed.

Passing urine may sting a little for a day after the test, but if you think that you have developed a urine infection please let your doctor know. The results of the test are usually available immediately and will be discussed with you so that your treatment can be planned.

Most types of contraception don't protect against sexually transmitted infections (STIs). Condoms are the only form of contraception that protects against STIs as well as preventing pregnancy. Therefore, if you're using another type of contraception, such as the contraceptive pill, you should also consider using a condom to protect yourself against getting an STI.

Condoms (male and female): Condoms are a form of barrier contraception. They prevent pregnancy by stopping sperm from reaching and fertilising an egg. Condoms also provide protection against STIs, including HIV, and stop them being passed from one sexual partner to another. Condoms are used during penetrative sex (vaginal or anal) and oral sex to protect against STIs.

Combined contraceptive pill: The combined contraceptive pill, usually just referred to as the pill, contains synthetic (man-made) versions of the female hormones oestrogen and progesterone, which women produce naturally in their ovaries. The pill is usually taken to prevent pregnancy but it can also be used to treat:

• painful periods
• heavy periods
• premenstrual syndrome
• endometriosis

Progestogen-only contraceptive pill: The progestogen-only pill doesn't contain any oestrogen. It is an option for women who can't use the combined contraceptive pill, such as those over 35 years old and those who smoke.

Contraceptive implants and injections: Contraceptive implants and contraceptive injections are long-acting, effective, reversible and progestogen-only methods of contraception. Implants are over 99% reliable in preventing pregnancy. They last for 3 years. This means that fewer than 1 in 100 women who use the implant will become pregnant each year. The injection is given into a muscle every 12 weeks and is 94 to 99.8% effective.

Diaphragms and caps: Diaphragms and caps are barrier methods of contraception used by women. They fit inside the vagina and prevent sperm from passing through the entrance of the womb (cervix).

Intrauterine device (IUD): An intrauterine device (IUD) is a small, T-shaped contraceptive device made from plastic and copper that fits inside the womb (uterus). The IUD used to be called a coil or a loop. It's a long-acting and reversible method of contraception, which can stay in the womb for 5-10 years depending on the type.

Some IUDs contain hormones that are gradually released to prevent pregnancy. These IUDs can also be used to manage heavy periods. IUDs are more than 99% effective.

Intrauterine system (IUS): The intrauterine system (IUS) is similar to the intrauterine device (IUD), but it works in a slightly different way. Rather than releasing copper like the IUD, the IUS releases the hormone progestogen, which prevents pregnancy. It's a long-acting, reversible method of contraception that lasts for 5 years. It can also be used for managing heavy periods.

Emergency contraception: A woman can use emergency contraception to prevent pregnancy after having unprotected sex, or if a method of contraception has failed. There are 2 types of emergency contraception:

• The emergency contraceptive pill (sometimes called the morning-after pill) — The emergency contraceptive pill is best taken in the 24 hours after you have unprotected sex. You can take up to 5 days later, but it will be less effective.
• Copper intrauterine contraceptive device (Cu-IUD) — An intrauterine device can also be an effective form of emergency contraception if fitted by a healthcare professional within 5 days (120 hours) of having unprotected sex. It will prevent about 99% of preganancies.

Vasectomy: Vasectomy or 'male sterilisation' is a simple and reliable method of contraception. It's usually considered permanent and is therefore a big decision that should be fully discussed with your GP beforehand. A vasectomy is a quick and relatively painless surgical procedure. It's usually done under local anaesthetic.

Female sterilisation: Female sterilisation is an effective form of contraception that permanently prevents a woman from being able to get pregnant. Like a vasectomy, female sterilisation is a big decision that should be fully discussed with your GP and / or your specialist.

The operation usually involves cutting or blocking the fallopian tubes, which carry eggs from the ovaries to the womb (uterus). This prevents the eggs from reaching the sperm and being fertilised. It's a fairly minor operation and many women can return home the same day.

Vaginal ring: The vaginal ring is a small, soft plastic ring that's placed inside the vagina on the first day of a woman's period. It is removed after 21 days. A new ring is used 7 days later. A vaginal ring is about 4mm thick and 5.5cm in diameter. It contains oestrogen and progestogen, so it's not suitable for women who can't take oestrogen-containing contraception.

Natural family planning (fertility awareness-based methods): Natural family planning (also known as fertility awareness-based methods) is when natural signs, such as cervical fluid or body temperature, are used to identify when a woman is at her least and most fertile during each menstrual cycle. This can be used to help either avoid or plan a pregnancy.

Natural family planning is estimated to be around 75 to 99.6% effective — so it’s possible that you will still become pregnant if you use this approach. There are several fertility awareness-based methods of birth control and while some are highly effective, others are less so. Apps that track and predict a woman’s menstrual cycle are not generally accurate enough for birth control purposes.

It's possible to become pregnant again very soon after the birth of a baby, even if you're breastfeeding and even if your periods haven't returned. You ovulate (release an egg) about 2 weeks before your period arrives, so your fertility may have returned before you realise it.

It's important to sort out contraception from the start. If you had your baby in hospital, you should discuss contraception with your doctor or midwife before going home. You'll also be asked about contraception at your 6-week postnatal check, but you can discuss it at any time with your midwife, doctor or local family planning / sexual health clinic.

You can use male and female condoms as soon as you feel ready to have sex. The combined pill, progestogen-only pill and contraceptive implants can be used from 21 days after the birth. However, the combined pill is not recommended if you are breastfeeding because it can affect your milk supply.

You can usually have a contraceptive injection or start using a diaphragm or cap around 6 weeks after giving birth. If you used a diaphragm or cap before becoming pregnant, see your doctor or family planning / sexual health clinic after the birth to ensure that it still fits correctly. Childbirth and other factors such as weight loss/gain can have a significant effect. An IUD or IUS can usually be fitted 6-8 weeks after giving birth.

The effectiveness of contraception depends on factors such as

• your age
• how often you have sex
• whether you use the contraceptive correctly

Most types of contraception are over 99% effective if used correctly. However, the most effective reversible methods are the "fit and forget" long-acting reversible contraceptives (LARCs) - intrauterine devices (IUDs) and contraceptive implants.The male condom is 98% effective if it's used correctly and consistently. It's the only type of contraception that protects against STIs as well as pregnancy.

Places where you can get contraception include:

• your doctor
• a sexual health or family planning clinic
• your pharmacy

You may need to change the type of contraception that you use as you get older, after having children, or if your sex life changes in any way.

Fertility usually starts to decline from around age 37, although you will still need to use contraception after this time to prevent unplanned pregnancy. Most women will have reached the menopause by the time they're 55 years old and can usually be advised to stop using contraception around this time.

Colposcopy is a procedure that uses a special microscope (called a colposcope) to look into the vagina and to look very closely at the cervix (the opening to the uterus, or womb).

The colposcope magnifies, or enlarges the image of the outer portion of the cervix. It is somewhat like looking through a pair of binoculars. This allows the doctor to see the outer portion of the cervix better. Sometimes a small sample of tissue (called a biopsy) is taken for further study. The tissue samples help the doctor to figure out how to treat any problems found. If cancer of the cervix is found early, or a precancerous change of cells is found,it can be treated and almost always can be cured. Also, for precancers and early cancers of the cervix, sometimes removal of part of the cervix may be the only treatment needed.

These abnormalities may range from inflammation, infection, pre-cancerous or cancerous changes in the cells of the cervix.  It is important to remember that cancer is rare and most of the changes noted at the time of a colposcopy will resolve spontaneously and require only follow-up checks.

Other reasons a woman may need a colposcopy is when, during a pelvic exam, the cervix, vagina, or vulva looks abnormal to the doctor

When you have a colposcopy, you will lie on an exam table just like you do when you have a regular pelvic exam. Dr Johnson uses an instrument called a speculum to spread the walls of the vagina apart. Dr Johnson then places the colposcope, which is like a microscope with a light on the end, at the opening of the vagina. The colposcope does not enter the vagina. Dr Johnson will look inside the vagina to locate any problem areas on the cervix (opening to the uterus) or in the vagina. If any areas are of concern, Dr Johnson may take a small tissue sample (called a biopsy). When this is done you may feel a slight pinch or cramp. The tissue is then sent to a lab for further study.

The procedure is short and takes approximately 10-15 minutes and is performed at the time of your consultation. There is no need for any anaesthesia

Most women feel fine after a colposcopy. You may feel a little lightheaded and if you had a biopsy, you may have some light bleeding. Subsequent spotting may persist for several days following a colposcopy but should not be heavy.  Please use panty liners for hygiene and NOT tampons during this time.

There may be some cramping after a colposcopy, especially if a biopsy is taken. This occurs because the touching of the cervix causing may lead to uterine contractions similar to period pain, and may be treated in a similar manner by using medications such as naprogesic, nurofen or ibuprofen.  You should not have sexual intercourse until any discharge stops, usually for the next 3-5 days.

Dr Johnson will talk with you about what he saw inside your vagina and cervix. If a sample of tissue was taken from your cervix (biopsy), the lab results should be ready in 2 to 3 weeks.

Uncommonly, heavy bleeding may occur from the site of biopsy.  We will ensure bleeding from the site has settled before we let you go home, however if you experience heavy bleeding immediately following the examination you should contact Dr Johnson.

Occasionally when the cervix is touched there may be a sensation of nausea and faintness. This occurs because of stimulation to nerve fibers in the cervix, which causes the blood pressure to drop. If this happens, let Dr Johnson know the symptoms and the procedure will be stopped and you will simply remain lying down and observed until the sensation passes in a few minutes.

Other risks include infection of the cervix may occur, particularly after a cervical biopsy is taken.  This is uncommon and antibiotics are not required as a routine.  Infection may occur in the first 10 days following the procedure and if you have persistent or offensive vaginal discharge, heavy bleeding, high temperatures, or increasing pain you should contact Dr Johnson for advice on what to do.

Menopause is defined as your last menstrual period. The average age of menopause is 51, occurring mostly between 45 and 55 years of age. Because your periods tend to become less frequent, menopause is only diagnosed after you have not had a period for one year. A natural menopause occurs because, as you get older, your ovaries stop producing eggs and make less oestrogen (the main female hormone). This causes your periods to stop, and your menopausal symptoms.

Menopause is a normal part of a woman’s life and does not always need to be treated. However, the changes that happen before and after menopause can be disruptive. If you have bothersome symptoms, effective treatments are available.

Although menopause is defined as the time when your periods actually stop, changes in your hormone levels will start to occur years before; this can lead to some of the symptoms of menopause before you stop your periods. This period is known as the peri-menopause. These changes can lead to:

• Irregular periods
• Hot flushes
• Night sweats
• Sleep problems
• Vaginal dryness

If you are 45 years of age or older, and you have not had a menstrual period in 12 months, there is a good chance that you are menopausal. Most women in this group do not need any lab testing to confirm menopause, especially if they are having menopausal symptoms, such as hot flushes or vaginal dryness. If you have not had menopausal symptoms, it is important to rule out pregnancy as the cause of your periods stopping.

Post-menopause starts a year after your last period.

Women who become menopausal before the age of 40 are considered to have an abnormally early menopause, and need to be treated differently. If you are less than 40 years of age and are not having periods, or are experiencing menopausal symptoms, you should see your doctor. Women may go through menopause early if

• They have surgery to remove their ovaries
• They have had radiotherapy to their pelvic area as a treatment for cancer
• Have undergone chemotherapy (some chemo drugs that treat cancer may lead to an early menopause)
• They have had a hysterectomy (removal of the uterus) before menopause (the ovaries sill still make oestrogen, but it is likely that the level of oestrogen will fall at an earlier age than average)
• Early menopause runs in their families

In some women who have an early menopause, no cause can be found.

Menopause can also occur when a woman’s ovaries are removed surgically. This may trigger severe symptoms, because the hormone levels decrease all at once. Although the removal of the uterus (hysterectomy) ends menstrual periods, it will only cause menopause if the ovaries are removed.

Periods do not tend to just stop. They change in nature, volume and frequency, leading up to menopause. As your hormones change towards menopause, your periods may be come more, or less, frequent. They may last longer or shorter times. You may also skip periods.

Because your bleeding pattern may become very variable, it has be difficult to know if vaginal bleeding is abnormal when you are near menopause. In general, you should see your doctor if you have the following symptoms –

• Vaginal bleeding more often than every three weeks
• Excessive heavy menstrual bleeding, especially if this is new
• Spotting between your periods
• Vaginal bleeding after menopause (even if it is just a spot of blood)

As the ovaries stop working, levels of oestrogen fall, leading to the typical symptoms of menopause. Some women have few, or no, menopausal symptoms, while other women have bothersome symptoms that interfere with their lives. About eight out of ten women will develop menopausal symptoms at some point. These symptoms often begin before you stop having periods. The most common symptoms of menopause include –

• Hot flushes. Hot flushes occur in three out of four women. They typically begin as a sudden feeling of heat in the upper chest and face. The hot feeling then spreads throughout the body and lasts for two to four minutes. Some women sweat during the hot flush and then feel chills and shiver and the hot flush ends. The number of hot flushes can vary from every now and then, to fifteen or more a day. Hot flushes tend to start just before the menopause and, typically, persist for two to three years. Some women have a feeling of anxiety or heart palpitations during the hot flush. It is not clear what causes hot flushes.
• Night sweats. When not flushes happen during sleep, they are called night sweats. Night sweats may cause you to sweat through your clothes and wake up from sleep, because you are hot or cold. This can happen once or more times per night. Waking frequently can make it difficult to get a good night’s sleep. As a result of interrupted sleep, many women develop other problems, such as fatigue, irritability, trouble concentrating as well as mood swings.
• Sleep problems. During the transition to menopause, some women begin to have trouble falling asleep, or staying asleep, even if night sweats are not a problem. Sleep problems can cause you to feel tired and irritable the next day.
• Vaginal dryness. As the levels of oestrogen in the blood fall before, and during menopause, the tissues inside the vagina and urethra (tube from the bladder to the outside of the body) can become thin and dry. This can cause you to have vaginal dryness or irritation, or to have pain and dryness with sex. Your vulva (skin next to your vagina) may become thin, dry and itchy. Some women develop problems with recurrent urine infections.
• Skin and hair changes. You tend to lose some skin protein (collagen) after menopause. This makes the skin drier, thinner and more likely to itch.
• Depression. During the menopausal transition, some women develop new problems with mood, such as sadness, difficulty concentrating, feeling disinterested in normal activities, and sleeping too much, or having trouble staying asleep. Women with a past history of depression can feel more blue moods during the menopausal transition. If you have any symptoms of depression, or the blues that will not go away, talk to your doctor.

In around 10% of women, symptoms may persist for more than a decade.

• Osteoporosis. As you become older, you gradually lose bone tissue. Your bones become less dense and less strong. The amount of bone loss can vary. If you have lots of bone loss, then you have osteoporosis. Having osteoporosis will cause you to have bones that will break more easily than normal, especially if you have an injury such as a fall. Women lose bone tissue more rapidly than men, especially after the menopause when the level of oestrogen falls. Oestrogen helps protect against bone loss.
• Heart attack and stroke. The oestrogen produced by women’s ovaries before menopause helps to protect them from heart attacks and stroke. When less oestrogen is made, women lose much of this protection. The risk of heart attack and stroke then increases. One of the reasons for taking HRT in the past was to help to protect against cardiovascular disease, by keeping oestrogen levels higher for longer. However, studies have since shown that some forms of HRT do not actually protect against all cardiovascular diseases and may actually increase your risk.
• Libido. Some women find that they have less interest in sex around and after menopause. Lower hormone levels may decrease your sex drive and may affect your ability to have an orgasm, or it may take longer for you to reach orgasm.

Although most women are less likely to become pregnant (without infertility treatment) after the age of 45, it is still possible, especially if you are having monthly periods and having sex regularly. If you do not want to become pregnant, you should continue to use some form of birth control until a year after your last period. Once you become menopausal, you cannot get pregnant.

If you are using a hormonal method of birth control, such as the Pill, an injection or a vaginal ring, talk to your doctor to find out when you should stop. The risks of taking oestrogen-containing contraception increase as you get older. You should review this with your doctor to find out if it is still appropriate for you.

Alternatively you can switch to a barrier method of birth control.

If you are using an IUD, you can have it removed when it expires (after 3 years for most copper IUDs, after five years for levonorgestrel IUDs (such as Mirena). If you are over the age of 51 and do not recommence periods after the removal of the IUD, you no longer need contraception. If you are using Mirena IUD for the purpose of reducing the period blood flow, then you may leave the Mirena for until the age of 55, as it is difficult to ascertain if you have finished periods or not

If you do not have a uterus (eg, after hysterectomy), but you still have ovaries, it can be difficult to know when you are menopausal, because you will not have periods. You may develop menopausal symptoms as your ovaries stop working and your blood levels of oestrogen begin to fall. If you are having bothersome symptoms of menopause after hysterectomy, talk to your doctor.

Not all women will need treatment for menopausal symptoms, especially if the symptoms are mild. In fact, there are thinks that you can do on your own that might help you to cope with the symptoms you have.

MAIN POINTS

• MHT (also known as Hormone Replacement Therapy or HRT) covers a range of hormonal treatments that can reduce menopausal symptoms.
• MHT is the most effective way to control menopausal symptoms while also giving other health benefits.
• MHT is safe to use for most women in their 50s or for the first 10 years after the onset of menopause.
• The added risk for blood clots, stroke and breast cancer while taking MHT is very small, and similar to that for many other risk factors such as being overweight.
• Different types of MHT are associated with different risks. Your doctor can work with you to reduce your risk by using different hormonal treatment options.

At menopause, a decrease in oestrogen levels can cause symptoms such as hot flushes, vaginal dryness, mood and sleep changes. If your symptoms are bothering you and you would like to know more about MHT, your doctor can help. Your doctor can tell you about the changes in your body and offer options for managing your symptoms.

Menopausal Hormone Treatment or MHT (also known as Hormone Replacement Therapy or HRT) is the most effective way of improving menopausal symptoms. MHT can also benefit your health by improving bone density and reducing the risk of fractures. MHT may also reduce the risk of a fracture and heart disease for some women. If you have had hormone-dependent cancer, you should not take hormone therapies. Speak with your doctor about other non-hormonal prescription medications.

Types of MHT (HRT):MHT is available as tablets, patches, gels or vaginal treatments. The type of MHT needed and the associated risks varies according to:

• your age
• whether you have had a hysterectomy
• whether you have other health conditions.

Your doctor can tailor the type of hormone treatment best suited to you. If you had an early menopause you should continue treatment at least until the average age of menopause (51 years).

If you still have your uterus (have not had a hysterectomy), then you need a treatment that combines oestrogen and progestogen. Progestogens (including norethisterone, medroxyprogester , one dydrogesterone and micronized progesterone) are added to the treatment to reduce the risk of cancer of the uterus. Safety facts:

• Does not cause weight gain
• Blood clots – patches and gels have minimal or no risk. When using tablets the risk doubles, but is still very low (1 extra case per 1,000 women).
• Heart disease – no increased risk if MHT begins within 10 years of onset of menopause or before the age of 60.
• Breast cancer - overall 1 in 8 women will develop breast cancer during her lifetime. The added risk of breast cancer with MHT is very small. The risk increases the longer you take MHT and decreases after stopping. Using a different progestogen may reduce the risk.
• Stroke – no increased risk for women without underlying stroke risk factors who are in their 50s or during the first 10 years of menopause. Women with risk factors can probably safely use a patch or gel form of treatment. 

Oestrogen alone is suitable for women who have had a hysterectomy.

Safety facts:

• Blood clots – patches and gels have minimal or no risk. When using tablets the risk doubles, but is still very low (1 extra case per 1000 women).
• Heart disease – may decrease the risk of heart disease if started within 10 years of menopause or before the age of 60.
• Breast cancer - overall 1 in 8 women will develop breast cancer during her lifetime. Studies suggest that there is either no increase, or a very small added risk of breast cancer when using oestrogen only MHT. Breast cancer risk is lower with oestrogen only MHT compared with oestrogen plus progestogen.
• Stroke – no increased risk for women without underlying stroke risk factors who are in their 50s or during the first 10 years of menopause. Women with risk factors can probably safely use a patch or gel form of treatment.

Vaginal oestrogen therapy is useful for women who have local symptoms such as vaginal dryness.

Safety fact: 

• If used as supplied, vaginal oestrogen therapy is safe to use long-term, except after breast cancer.

Tibolone is taken as a single tablet and has some oestrogen, progesterone and testosterone effects. Many, but not all, women find tibolone helps with symptoms and may also improve sexual function. Tibolone is also suitable to reduce the risk of osteoporosis (thinning of the bones) in post-menopausal women.

Safety facts:

• Blood clots – no increase in risk.
• Heart disease – no increase in risk.
• Breast cancer – reduces breast density/tenderness and no increase in breast cancer risk with three years of use.
• Stroke – increase in risk if started after the age of 60.

SERMS (selective oestrogen receptor modulators) are a newer treatment option for menopause. They have anti-oestrogen or oestrogen-like effects that vary in different parts of the body. A tablet containing conjugate equine oestrogen combined with the SERM bazedoxifene improves menopausal symptoms, bone density and reduces breast density. Bazedoxifene, like progestogen, reduces the risk of cancer of the lining of the uterus in women who have not had a hysterectomy.

Safety fact: 

• SERMs can be combined with oestrogen to improve symptoms, improve bone density and reduce the risk of uterine cancer.

If your symptoms are bothering you, your doctor can help. Your doctor can tell you about the changes in your body and offer options for managing your symptoms. Other fact sheets about treatment options include:

• Non-hormonal treatment options (See AMS fact sheet – Non-hormonal treatment options for menopausal symptoms)
• Lifestyle changes and menopause (See AMS fact sheet – Lifestyle and behaviour changes to manage menopausal symptoms)
• Complementary therapies (See AMS fact sheet – Complementary medicine options for menopausal symptoms)

Information for your doctor to read includes AMS Information Sheets:

• Risks and benefits of MHT
• AMS Guide to equivalent MHT/HRT doses Australia only or AMS Guide to equivalent MHT/HRT doses New Zealand only
• Combined MHT
• Oestrogen only MHT
• Tibolone for post-menopausal women

Polycystic Ovarian Syndrome is a common hormonal disorder among women of reproductive age. It can affect you from adolescence to older age. The symptoms are -

• irregular, or prolonged, periods
• increased weight
• Infertility
• excessive hair growth all over
• acne
• male-pattern baldness

At different stages of life it can express itself in different ways, eg, in adolescence, absence of or infrequent menstruation may be a sign, associated with an increase in weight and excessive hair growth. In women past adolescence, it can express itself as an irregular ovulation cycle, leading to pregnancy issues, unexplained weight gain and/or difficulty in losing weight and difficulty in falling pregnant.

The exact cause of PCOS is unknown; however, following factors may contribute to the problem.

Excessive Insulin. This condition causes insulin-resistance so that the pancreas has to produce more insulin, which can increase the production of androgen, therefore leading to acne, excessive hair growth and weight gain.

Excessive Androgen. This condition can cause male pattern hair growth and acne. It also prevents the ovaries from releasing an egg each month (missed ovulation), which can lead to infertility.

PCOS affects all areas of the body, not just the reproductive system. It creases a woman’s risk of serious conditions that my have lifelong consequences. Insulin resistance increases the risk of Type 2 diabetes mellitus and cardiovascular disease. Women with PCOS tend to have a condition called endometrial hyperplasia, in which the lining of the uterus (endometrium) becomes too thick. This condition increases the risk of endometrial cancer.

This is a life-long condition. In a nutshell, the complications are a higher risk of –

• Obesity
• Type 2 diabetes
• High blood pressure
• High cholesterol and lipids
• Sleep apnoea
• Heart attack and stroke
• Endometrial cancer
• Abnormal uterine bleeding
• Gestational diabetes
• Subfertility

A thorough medical history physical examination, pelvic examination blood tests and androgen/insulin levels, a BSL lipid profile and a pelvic ultrasound, (slightly large ovaries, containing numerous small cysts in a pearl-necklace appearance)

• As little as a 5% reduction in body mass may help a woman to ovulate.
• Consider dietary changes such as a low fat and low carbohydrate diet, which will decrease insulin levels and weight
• Weight reduction
• Exercise, which can lower blood sugar levels

Oral contraceptive pills or Mirena IUCD are a first line to regulate the periods and to prevent an increase in the thickness of the endometrium

Clomid/Metformin, which can induce ovulation, if the problem is infertility

Spironolactone or contraceptive pills, which decrease androgen production, therefore reducing excessive hair growth and acne

Laparoscopic ovarian drilling, which can reduce androgen formation

Endometriosis is a condition in which the tissue that forms the lining of the uterus (the endometrium) is found outside the uterus. Some women with endometriosis have few or no symptoms, while others have pain or difficulty in becoming pregnant.

Although it has been found in many places in the body, the most common places where endometriosis occurs are the lining of the abdomen (peritoneum) in the pelvis, the ovaries, the fallopian tubes, the bowel, and the areas around the uterus (front, back, sides).

There is no cure for endometriosis, but there are several treatment options. The treatment depends on the individual situation.

Overall, the prevalence of endometriosis is not known, because it requires an operation to diagnose it. Many women have either no symptoms, or very mild symptoms, which do not warrant an operation.

The cause of endometriosis is not known.

A common theory is that some menstrual blood and endometrium flows backwards through the fallopian tubes and into the pelvis during a period. This tissue then grows where it lands in the pelvis. This is called the retrograde (backwards) menstruation theory. There are also several other theories.

Endometriosis implants respond to changes in oestrogen. The implants may grow and bleed like the uterine lining does during the menstrual cycle. Surrounding tissue can become irritated, inflamed and swollen. The breakdown and bleeding of this tissue each month can also cause scar tissue (adhesions) to form. Sometimes adhesions can cause organs to stick together. The bleeding, inflammation and scarring can cause pain, especially before and during menstruation.

Some women with endometriosis have no symptoms. The most common symptom is pelvic pain, especially with periods.

Pain may occur -

• Just before or during your period
• Between periods, with worsened pain during the period
• During, or after, sexual intercourse
• With bowel movements, or while urinating, especially during your period

Pelvic pain can also be caused by many other conditions such as pelvic infections, bladder conditions and irritable bowel syndrome. Often women with endometriosis have more than one condition contributing to their pain.

Your doctor might suspect that you have endometriosis based on your symptoms of pelvic pain or painful periods. However, the only way to know for sure is to have surgery. This is usually a laparoscopy (keyhole surgery). Sometimes a small amount of tissue is removed during the procedure, to confirm he diagnosis. This is called a biopsy.

Endometriosis is considered mild, moderate or severe, depending on what is found during surgery. The severity of endometriosis is difficult to predict, based on symptoms alone. Women with mild disease can have severe symptoms; women with severe disease can have mild symptoms.

Apart from pain, endometriosis can cause –

• Difficulty in falling pregnant. Endometriosis can make it more difficult to become pregnant. This might occur because endometriosis causes scar tissue to develop, which can damage the ovaries or fallopian tubes. However, even women with endometriosis who do not have scar tissue can have difficulty in becoming pregnant. With women who become pregnant, endometriosis does not harm the pregnancy. Symptoms of endometriosis often improve after pregnancy.
• Ovarian cysts (endometriomas). Women with endometriosis can develop ovarian cysts containing endometriosis. This is called an endometrioma. Endometriomas are usually filled with old blood that resembles chocolate syrup, thus they are sometimes called chocolate cysts. Endometriomas are sometimes seen during a pelvic ultrasound or felt during a pelvic examination. Most women with endometriomas will also have endometriosis elsewhere in their pelvis.

Treatment for endometriosis depends on the extent of the disease, your symptoms and whether or not you want to have children. Treatment may be with medication, surgery or both, and may include –

• Non-steroidal anti-inflammatory drugs
• Hormonal birth control
• Other forms of hormone treatment (gonadotropin-releasing hormone agonists)
• Surgery

When pain is the primary problem, medication is often tried first. If treatment does not improve your pain within three to six months, surgery is a reasonable next step. In other cases, surgery is performed to diagnose endometriosis and remove it before you take any medicine. The best treatment depends on your symptoms, age and future plans to become pregnant.

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are a type of pain medicine that can help to relieve the pain caused by endometriosis. The medicine works by stopping the release of prostaglandins, one of the main chemicals responsible for painful menstrual periods. NSAIDs do not shrink or prevent the growth of endometriosis. Most NSAIDs are available over the counter, including –

• Ibuprofen
• Naproxen sodium, sold as Naprosyn, and as store brands

NSAIDs do not always relieve endometriosis-related pain. NSAIDs probably work better when combined with other treatments, such as hormonal birth control. Serious side-effects from NSAIDs, although uncommon, include stomach upset, kidney problems and worsened high blood pressure. Be sure to follow the instructions closely.

Hormonal birth control treatments

Hormonal birth control, including the combined pill, injectable, implantable and intrauterine progestins (IUD) are often helpful in treating pain, because they reduce heavy bleeding. Hormonal birth control works best in women who do not have severe pain.

Combined oral contraceptive pill (containing both oestrogen and progestins)

Women with endometriosis taken the Pill are often advised to skip their periods and take hormone-containing pills continuously for three, or more, months. This allows you to have fewer periods and have less pain and bleeding during each period. The most common side-effects for hormonal birth control are –

• Nausea
• Breast tenderness
• Irregular vaginal bleeding or spotting

These side-effects usually improve after using the treatment for several months.

Progestins

Progestins are a synthetic form of a natural hormone called progesterone. This treatment might be recommended for women who do not get pain-relief from, or who cannot take, hormonal birth control that contains oestrogen (such as smokers). Progestins are available by prescription and are usually given as a pill, implant, IUD or injection. Side-effects of progestins can be bothersome for some women. The most common side-effects include -

• Bloating
• Weight gain
• Irregular vaginal bleeding
• Worsened depression (rarely)

Gonadotropin-releasing hormone agonists

Gonadotropin-releasing hormone (GnRH) agonists are medicines that work by causing a temporary menopause. They are not commonly used in endometriosis treatment because they can only be taken for a short period of time, may cause menopausal side-effects and re expensive. Most endometriosis requires longer-term treatment. The treatment causes the ovaries to stop producing oestrogen, which causes the endometriosis implants to shrink.

No hormonal treatment can be used of you are trying to fall pregnant.

Surgery may be performed if you -

• Have severe pain
• Have tried medicines, but still have bothersome pain
• Have a cyst or mass in the pelvic area
• Are having trouble getting pregnant, and when endometriosis might be the cause

Laparoscopy is most commonly used to diagnose and treat endometriosis. The goal of surgery is to remove endometriosis implants and scar tissue. More than 80% of women who have surgery have less pain for several months after surgery. However, there is a good chance that the pain will back, unless you take some form of treatment after surgery (such as hormonal birth control).

If pain is severe and does not go away after treatment and you do not want to become pregnant in the future, your doctor may discuss a hysterectomy and removal of your ovaries with you.

It is uncommon to require this treatment.

Chronic pelvic pain refers to pain in the lower half of your abdomen, lasting six months or longer. The pain may be in a small specific area or it may be throughout the pelvis. Having long-standing pelvic pain is common, it affects around 1 in 6 women. Long-term pain can be very difficult to live with. It may cause you emotional, social and even economic difficulties. You may experience depression, difficulties in sleeping and a disruption to your daily routine.

Chronic pelvic pain is a complex problem. It is not a disease in itself, it is a symptom which can be caused by many conditions. Often, however, an easily treatable cause is not found, therefore, chronic pelvic pain becomes a condition treated in its own right focusing on symptom relief rather than treating the cause of the pain. Even if no reason can be found for the pain, there are still treatments which will improve the pain and many women find that the quality of their lives improves when they get a better understanding of what is involved.

Chronic pelvic pain is experienced differently by each woman. Pain may be:

• Severe and constant Pain that comes and goes (intermittent)
• Dull aching
• Sharp pains or cramping
• Pressure or heaviness deep within your pelvis
• Pain during sex
• Pain when using your bowels
• Pain when you sit down

Your discomfort may intensify after standing for long periods and may be relieved when you lie down. The pain may be mild and annoying, or it may be so severe that you miss work, can't sleep and can't exercise.

Many conditions can cause chronic pelvic pain. It is often caused by a combination of physical, psychological and/or social factors, rather than a single underlying condition.

Sometimes we don’t find a specific cause. This does not mean that you don’t have real pain, just that a cause is not always easy to find. Gynecologic causes are thought to be the cause of chronic pelvic pain in about 20 percent of women. However, other diseases can cause pelvic pain. In addition, psychological factors may contribute to your pain.

Some causes of chronic pelvic pain include:

• Endometriosis - a condition where cells of the lining of the womb (the endometrium) are found elsewhere in the body, usually in the pelvis. These deposits of tissue respond to your hormones, just like your uterine lining does. Because it's happening outside your uterus, the blood and tissue can't exit your body through your vagina. Instead, they remain in your abdomen, where they may lead to painful cysts scar tissue (adhesions).
• Adenomyosis - a condition where the endometrium is in pockets within the muscle wall of the womb. This can cause heavy bleeding and pain with your period.
• Pelvic inflammatory disease (PID) (an infection of the womb, fallopian tubes and/or pelvis) This can occur if an infection, often sexually transmitted, has caused scarring involving your pelvic organs.
• Painful bladder syndrome and interstitial cystitis — Painful bladder syndrome and interstitial cystitis (PBS/IC) are the terms given to bladder pain that is not caused by infection. Symptoms usually include the need to urinate frequently (frequency) and a feeling of urgently needing to urinate (urgency). Some women with painful bladder syndrome have lower abdominal or pelvic pain in addition to urinary tract symptoms.
• Musculoskeletal pain (pain in your joints, muscles, ligaments and bones) which may be perceived as pain in your pelvis
• Irritable bowel syndrome (IBS) - In addition to pain it often causes bloating, constipation and/or diarrhoea in the absence of any other cause
• Diverticulitis - A diverticulum is a sac-like protrusion that sometimes forms in the muscular wall of the colon (or intestine). Diverticulitis occurs when diverticula become inflamed. This usually causes abdominal pain; nausea and vomiting, constipation, diarrhea, and urinary symptoms can also occur.
• Pelvic floor pain – this may cause pelvic pain, pain with urination, difficulty urinating, constipation, pain with intercourse, or frequent/urgent urination. Sometimes this occurs in response to other conditions which have been causing pain. Pelvic floor dysfunction can be diagnosed by a clinician feeling the pelvic floor muscles (muscles that support the pelvic organs and hips) through the vagina and/or rectum; muscles that feel tight, tender, or band-like indicate that pelvic floor dysfunction could be contributing to pelvic pain.
• Abdominal myofascial pain (trigger points) — Pain can originate from the muscles of the abdominal wall due to myofascial pain. This problem usually has small localized areas of abnormal tenderness of the abdominal muscles that are called trigger points. Abdominal myofascial pain is diagnosed by the clinician examining the abdominal muscles for trigger points; often tightening of these muscles while they are examined causes increased pain and assists in diagnosis.
• Ovarian remnant – sometimes after a hysterectomy (removal of uterus), ovarian tissue may become trapped beneath scar tissue and later develop painful cysts.

Understandably, all women who suffer from chronic pain regardless of the cause will have some psychological effect from it. Psychological factors, such as depression, chronic stress or a history of sexual or physical abuse may increase your risk of developing chronic pelvic pain. Emotional distress makes pain worse, and living with chronic pain contributes to emotional distress.

If pain is bothersome, persistent and not settled with simple over the counter pain medication you should see your doctor.

At your first appointment, you should have the chance to describe the pain you have experienced and discuss your anxieties. It often requires some extra time so make sure you book a longer appointment with your doctor.

Although at times you may feel you are repeating yourself, your story is important. The way you describe your symptoms is crucial in making a diagnosis. Your doctor will probably ask you a number of questions about:

• the pattern of your pain
• what makes your pain better or worse (certain sorts of movement, for example)
• whether you have noticed other problems that might be linked to the pain (sex, bladder, bowel or psychological symptoms, for instance)

It is therefore, a good idea to start keeping a pain diary before your appointment. This involves noting down when your pain occurs, how severe it is, how long it lasts and the things that seem to affect it. A pain diary will also help you to describe your pain and to become more aware of the ways in which it affects you.

You may be asked about aspects of your everyday life including your sleep patterns, appetite and general wellbeing. You may also be asked about how you are feeling and whether you are feeling depressed or tearful. This is because long-term pain is known to cause depression, which in turn may make your pain worse. If your doctor knows how your pain is affecting you personally, this can be taken into account with your treatment.

Your doctor will then undertake a thorough physical examination. This may include a pelvic and rectal examination. A pelvic examination can reveal signs of infection, abnormal masses or tense pelvic floor muscles. Your doctor will check for areas of tenderness and changes in sensation. Let your doctor know if you feel any pain during this exam, especially if the pain is similar to the discomfort you've been experiencing.

Figuring out what's causing your pain often involves a process of elimination. Possible tests your doctor might suggest include:

• Blood tests – to check for signs of infection
• Vaginal swabs or urine tests – to check for infections
• Ultrasound - This is usually a transvaginal scan (where the probe is gently inserted into your vagina) to look more closely at the uterus, fallopian tubes and ovaries. Usually this is not painful, however, if you have pelvic pain it may cause some tenderness
• Other imaging tests. Your doctor may recommend abdominal X-rays, computerized tomography (CT) scans or magnetic resonance imaging (MRI) to help detect abnormal structures or growths.

These tests are usually arranged by your GP. If they have found a cause but are unable to treat it themselves or they have not found the cause they may refer you on to a specialist. This will probably be a gynaecologist, a urologist or bowel doctor depending on what your GP thinks is the most likely cause of your pain. Ask your GP to refer you to a specialist with a special interest in pelvic pain.

What Happens Next?

Your gynaecologist will review your history and examine you again. They may discuss performing a laparoscopy to help diagnose and treat the pain. During laparoscopy, your doctor makes a small incision in your belly button and inserts a thin tube attached to a small camera (laparoscope). The laparoscope allows your doctor to view your pelvic organs and check for abnormal tissues or signs of infection in your pelvis. This procedure is especially useful in detecting endometriosis and chronic pelvic inflammatory disease.

Finding the underlying cause of chronic pelvic pain can be a long process, and in many cases, a clear explanation may never be found. With patience and open communication, however, you and your doctor can develop a treatment plan that helps you live a full life.

What treatment may help?

If your doctor can pinpoint a specific underlying cause, your treatment will focus on eliminating that particular cause. However, if you're unable to find the cause of your pelvic pain, treatment will focus on managing your pain. Treatment for long-standing pain usually involves multiple therapies and lifestyle changes. We do not have any treatments which will take the pain away instantly or completely. The focus of treatment is to achieve a level of pain that is tolerable enough that you may return to your usual activities.

Medications Depending on the underlying cause, your doctor may recommend a number of medications to treat your condition, including:

• Pain relievers. Over-the-counter pain remedies, such as aspirin, ibuprofen or paracetamol may provide partial relief from your pelvic pain. Sometimes a stronger prescription pain reliever may be necessary. Pain medication alone, however, rarely solves the problem of chronic pain.
• Hormone treatments. The days when you have pelvic pain may coincide with a particular phase of your menstrual cycle and the hormonal changes that control ovulation and menstruation. Birth control pills or other hormonal medications may help relieve cyclic pelvic pain.
• Antibiotics. If an infection is the source of your pain, your doctor may prescribe antibiotics.
• Antidepressants. Antidepressants can be helpful for a variety of chronic pain syndromes. Tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and others, seem to have pain-relieving as well as antidepressant effects. They may help improve chronic pelvic pain even in women who don't have depression.

Therapies Your doctor may recommend specific therapies or procedures as a part of your treatment for chronic pelvic pain. These treatments may include:

• Physical therapy and exercise. Applications of heat and cold to your abdomen, stretching exercises, massage and other relaxation techniques may improve your pain. A physiotherapist may recommend exercises to strengthen or relax your pelvic floor muscles. In addition, strength and aerobic exercise will help your feeling of general wellbeing. Your physiotherapist or doctor can advise you on what exercises are appropriate.
• Transcutaneous electrical nerve stimulation (TENS). This approach may help improve localized or regional pain. During TENS therapy, electrodes deliver electrical impulses to nearby nerve pathways — which can help control or relieve some types of pain.
• Counseling – recognizing the role that psychological factors play in worsening your symptoms is an important element in treating your pain
• Trigger point injections. If your doctor finds a specific point where you feel pain, a possible treatment option is the direct injection of a numbing medicine into a painful spot (trigger point). The medicine, usually a long-acting local anesthetic, can block pain and ease discomfort.

Surgery To correct an underlying problem, your doctor may recommend a surgical procedure:

• Laparoscopic surgery. In some instances, pelvic adhesions or endometrial tissue can be removed by laparoscopic surgery. During laparoscopic surgery, your surgeon performs an operation through several small incisions in your abdomen, using instruments with an attached camera.

Not all these treatments are appropriate for every woman. You will often need to try a combination of treatment approaches before you find what works best for you.

Your doctor or specialist practitioner should give you full detailed information about the risks and benefits of any investigation, surgical procedure and treatment suggested. There are no risks associated with having an ultrasound scan.

Non-medical therapies play an important role in managing chronic pelvic pain. Depending on your medical history, life situation and test results, your doctor may be able to tell you how likely these alternative therapies are to relieve your symptoms.

Learn strategies for managing stress. Becoming too anxious or stressed over certain situations may exacerbate chronic pain. Effective stress management techniques not only help reduce your stress levels but may also have the indirect effect of easing stress-triggered pain. Try to use relaxation and stress-reduction techniques that have worked for you in the past, such as exercise, yoga,meditation or simple deep breathing.

Acupuncture. During acupuncture treatment, a practitioner inserts tiny needles into your skin at precise points. Pain relief may come from the release of endorphins, your body's natural painkillers, but that's only one of many theories about how acupuncture works. Acupuncture isn't safe if you're taking blood thinners or if you have low blood counts.

Your doctor may not be able to predict what might happen for you as an individual. For many women the pain gets better with time. Most women have no serious or lifethreatening problem underlying the pain. Many women find that they can cope better with their pain after they have been given a thorough explanation of the nature of the pain, including previous test results and possible causes of the pain. They can also cope better when they feel reassured that there is no serious or life-threateningdisease present.

You should visit your doctor if you experience any of the following:

• bleeding from your rectum
• a change in your bowel habits which has lasted for more than six weeks
• new pain after you have passed the menopause
• any unusual swelling in your abdomen
• suicidal thoughts
• excessive weight loss
• irregular vaginal bleeding, such as bleeding between periods, or vaginal

bleeding after the menopause or vaginal bleeding during or after sex.

Chronic pelvic pain is a difficult and complex problem but you are not alone. No treatment will work all the time for everyone but we will find ways to improve your quality of life. You have the right to be fully informed about your health care and have the opportunity to share in making decisions about it.  If you are not comfortable with the final diagnosis, you can ask for a second opinion or ask your GP to refer you to a doctor or clinic that specializes in

Painful intercourse or dyspareunia occurs in many women at some point in their lives.

It is defined as persistent or recurrent genital pain that occurs just before, during or after intercourse. Talk to your doctor if you're experiencing painful intercourse. Treatments focus on the underlying cause which can be physical or psychological

• Superficial dyspareunia: Pain only at the time of penetration
• Pain with coitus, even when putting in a tampon
• Pain with certain partners or just under certain circumstances
• New pain after previously pain-free intercourse
• Deep pain during thrusting, often described as a stabbing pain
• Burning pain or aching pain after intercourse

Insufficient lubrication

• Not enough foreplay
• Drop in oestrogen levels after menopause, after childbirth or during breast-feeding
• Certain medications inhibit desire or arousal such as antidepressants, high blood pressure medications, sedatives, antihistamines and certain birth control pills.

Injury, trauma or irritation.

• Injury or irritation from an accident, pelvic surgery, female circumcision, episiotomy or a congenital abnormality.

Inflammation, infection or skin disorder can cause a superficial pain at the beginning of the intercourse

Vaginismus

• Involuntary spasms of the muscles of the vaginal wall which often can be a protective measure to avoid pain

Deep pain

• Occurs with deep penetration and may be more pronounced with certain positions.

Pathological causes

• Such as endometriosis, pelvic inflammatory disease, uterine prolapse, uterine fibroids, cystitis, irritable bowel syndrome and ovarian cysts.

Surgeries or medical treatments.

• Scarring from surgeries that involve your pelvic area, including hysterectomy, can sometimes cause painful intercourse. In addition, medical treatments for cancer, such as radiation and chemotherapy, can cause changes that make sex painful.

Emotional factors, sexual abuse and psychological problems.

• Anxiety, depression, concerns about your physical appearance, fear of intimacy or relationship problems can contribute to a low level of arousal and a resulting discomfort or pain.

Stress

• Pelvic floor muscles tend to tighten in response to stress in life. This can contribute to pain.

A thorough Medical history, pelvic examination, vaginal swabs, pap smear and pelvic ultrasound +/- colposcopy will enable us to identify possible cause.

Conservative

• Medications: Oestrogen cream, ordinary vegetable oil is the best lubricant (most other lubricants have alcohol/preservatives which may act as an irritant)
• Therapy: Desensitisation therapy + counselling or sex therapy
• Drugs:Depending on the underlying problem antibiotics, oral Endep, Amitriptilin 2% cream vaginally or some anti-epileptic drugs may be used.
• LASER: a non-invasive treatment for reshaping and revitalising of scar tissue and atrophic mucosa of the vagina.
• Platelet Rich Plasma (PRP): a non-invasive treatment for reshaping and revitalising of scar tissue and atrophic mucosa of the vagina.
• Combination of LASER and PRP: will be the ultimate treatment of chronic atrophic vaginitis.

Surgical

• Reversal of the scar
• Laparoscopy: excision of endometriosis, removal of ovarian cyst, adhesiolysis, removal of the fibroids, etc.

• Switch positions: changing positions may help. Being on top of your partner during intercourse may regulate penetration to a depth that feels good to you.
• Communicate: what feels good and what doesn't? If you need your partner to go slow, say so.
• Don't rush: longer foreplay stimulates your natural lubrication delaying penetration until you are aroused.
• Use lubricants: olive oil and vegetable oil are most effective, cheap and readily available (plus, they have the added benefit of being common household products)

Until vaginal penetration becomes less painful and bothersome, you and your partner might find other options to be more comfortable, more fulfilling and more fun than your regular routine. Sensual massage, kissing and mutual masturbation can all be good alternatives to intercourse.

Adhesions are bands of scar tissues occurring between organs inside the abdomen and pelvis. They are formed during healing from pelvic surgery, Caesarean sections, infection or endometriosis.

Although the formation of scar tissue are a normal part of the healing process, adhesions can become problematic because they cause parts of the body that are not normally connected to stick to each other.

Adhesions can impair the normal movement of the pelvic organs and cause pelvic pain.

When adhesions block the ends of the fallopian tubes, they cause infertility.

When adhesions cause pain or other health problems, they can be removed by surgery allowing structures to move more freely. In the past, this was done using open abdominal surgery, but today it can be done using laparoscopic surgery because of the reduced trauma to the body.

Compared to open surgery, laparoscopic surgery itself reduced the rate of adhesions as less tissue is directly handled. The high-definition camera can produce magnified vision, allowing better control of bleeding and enhancing precision of the surgery. Other benefits of laparoscopic surgery include:

• Faster recovery
• Less pain
• Less scarring
• Shorter hospital stay and earlier return to normal activities

Once the adhesions are removed, various adhesion barriers can be placed inside the pelvis to stop adhesions reforming.

Every woman is individual and her situation requires an individual plan of management.

Dr Johnson helps diagnose following gynaecological cancers.

• Cervical Cancer
• Ovarian Cancer
• Uterus Cancer
• Vulvar and Vaginal Cancer

Dr Johnson then will organise referal to the gynaecology-oncology unit in the tertiary hospital.

The cervix is part of the female reproductive system, which also includes the fallopian tubes, uterus (womb), ovaries, vagina (birth canal) and vulva (external genitals).Also called the neck of the uterus, the cervix connects the uterus to the vagina. The cervix:

• produces moisture to lubricate the vagina, which keeps the vagina healthy
• opens to let menstrual blood pass from the uterus into the vagina
• produces mucus that helps sperm travel up the uterus and fallopian tubes to fertilise an egg that has been released from the ovary
• holds a developing baby in the uterus during pregnancy by remaining closed, then widens to let a baby be born through the vagina.

The cervix has an outer surface that opens into the vagina (ectocervix) and an inner surface that lines the cervical canal (endocervix).These two surfaces are covered by two types of cells:

Squamous cells – flat, thin cells that cover the outer surface of the cervix (ectocervix). Cancer of the squamous cells is called squamous cell carcinoma.

Glandular cells – column-shaped cells that cover the inner surface of the cervix (cervical canal or endocervix). Cancer of the glandular cells is called adenocarcinoma .

Cancer is a disease of the cells. Cells are the body’s basic building blocks – they make up tissues and organs. The body constantly makes new cells to help us grow, replace worn-out tissue and heal injuries.

Normally, cells multiply and die in an orderly way, so that each new cell replaces one lost. Sometimes, however, cells become abnormal and keep growing. In solid cancers, such as cervical cancer, the abnormal cells form a mass or lump called a tumour. In some cancers, such as leukaemia, the abnormal cells build up in the blood.

Not all tumours are cancer. Benign tumours tend to grow slowly and usually don’t move into other parts of the body or turn intocancer. Cancerous tumours, also known as malignant tumours, have the potential to spread. They may invade nearby tissue, destroying normal cells. The cancer cells can break away and travel through the bloodstream or lymph vessels to other parts of the body.

The cancer that first develops is called the primary cancer. It is considered localised cancer if it has not spread to other parts of the body. If the primary cancer cells grow and form another tumour at a new site, it is called a secondary cancer or metastasis. A metastasis keeps the name of the original cancer. For example, cervical cancer that has spread to the lungs is called metastatic cervical cancer, even though the main symptoms may be coming from the lungs.

The ovaries are part of the female reproductive system, which also includes the fallopian tubes, uterus (womb), cervix (the neck of the uterus), vagina (birth canal) and vulva (external genitals).

The ovaries are two small, walnut-shaped organs. They are found in the lower part of the abdomen (the pelvic cavity). There is one ovary on each side of the uterus, close to the end of the fallopian tubes.

Each ovary is made up of:

• epithelial cells – found on the outside of the ovary in a layer known as the epithelium
• germ (germinal) cells – found inside the ovaries, and eventually mature into eggs (ova)
• stromal cells – form connective (supporting) tissue within the ovaries, and make the hormones oestrogen and progesterone.

At puberty, the ovaries begin releasing an egg (ovum) each month in a process known as ovulation. The egg travels down the fallopian tube into the uterus. If the egg is fertilised by a sperm, it will implant itself into the lining of the uterus and grow into a baby. If the egg is not fertilised by a sperm, the lining is shed and flows out of the body through the vagina. This flow is known as a period or menstruation.

The hormones oestrogen and progesterone cause ovulation and menstruation. As you get older, the ovaries gradually produce less of these hormones. When the levels of oestrogen and progesterone fall low enough, periods become irregular and finally stop. This is known as menopause. After menopause, you can’t conceive a child naturally. The ovaries also become smaller.

Cancer is a disease of the cells. Cells are the body’s basic building blocks – they make up tissues and organs. The body constantly makes new cells to help us grow, replace worn-out tissue and heal injuries.

Normally, cells multiply and die in an orderly way, so that each new cell replaces one lost. Sometimes, however, cells become abnormal and keep growing. In solid cancers, such as cervical cancer, the abnormal cells form a mass or lump called a tumour. In some cancers, such as leukaemia, the abnormal cells build up in the blood.

Not all tumours are cancer. Benign tumours tend to grow slowly and usually don’t move into other parts of the body or turn intocancer. Cancerous tumours, also known as malignant tumours, have the potential to spread. They may invade nearby tissue, destroying normal cells. The cancer cells can break away and travel through the bloodstream or lymph vessels to other parts of the body.

The cancer that first develops is called the primary cancer. It is considered localised cancer if it has not spread to other parts of the body. If the primary cancer cells grow and form another tumour at a new site, it is called a secondary cancer or metastasis. A metastasis keeps the name of the original cancer. For example, cervical cancer that has spread to the lungs is called metastatic cervical cancer, even though the main symptoms may be coming from the lungs.

The uterus, or womb, is where a baby grows during pregnancy.It is part of the female reproductive system, which also includes the ovaries, fallopian tubes, cervix (neck of the uterus) andvagina (birth canal).

The position of the uterus – About the size and shape of a hollow,upside-down pear, the uterus sits low in the abdomen between the bladder and rectum. It is joined to the vagina by the cervix. On either side of the uterus are the ovaries, which contain the woman’s eggs(ova). The ovaries are connected to the uterus by the fallopian tubes.

The layers of the uterus – The uterus has two layers. The myometrium is the outer layer of muscle tissue and makes up most of the uterus. The endometrium is the inner layer or lining.

Menstruation – In a woman of child-bearing age, the endometrium becomes thicker each month to prepare for pregnancy. If no pregnancy occurs, the endometrium is shed and flows out of the woman’s body through the vagina. This flow is known as a woman’s period (menstruation).

Menopause – The ovaries produce oestrogen and progesterone,the hormones that control the release of eggs (ovulation) and menstruation. During menopause, the levels of these hormonesdecreases. This means the woman’s ovaries no longer release eggs,her periods stop and she is not able to become pregnant. The uterus becomes smaller and the endometrium becomes thinner.

Cancer is a disease of the cells. Cells are the body’s basic building blocks – they make up tissues and organs. The body constantly makes new cells to help us grow, replace worn-out tissue and heal injuries.

Normally, cells multiply and die in an orderly way, so that each new cell replaces one lost. Sometimes, however, cells become abnormal and keep growing. In solid cancers, such as cervical cancer, the abnormal cells form a mass or lump called a tumour. In some cancers, such as leukaemia, the abnormal cells build up in the blood.

Not all tumours are cancer. Benign tumours tend to grow slowly and usually don’t move into other parts of the body or turn intocancer. Cancerous tumours, also known as malignant tumours, have the potential to spread. They may invade nearby tissue, destroying normal cells. The cancer cells can break away and travel through the bloodstream or lymph vessels to other parts of the body.

The cancer that first develops is called the primary cancer. It is considered localised cancer if it has not spread to other parts of the body. If the primary cancer cells grow and form another tumour at a new site, it is called a secondary cancer or metastasis. A metastasis keeps the name of the original cancer. For example, cervical cancer that has spread to the lungs is called metastatic cervical cancer, even though the main symptoms may be coming from the lungs.

The vulva and the vagina are parts of the female reproductive system,which also includes the ovaries, fallopian tubes, uterus and cervix.

The vulva

The vulva is a general term for a female’s external sexual organs(genitals). The main parts of the vulva are the:

• mons pubis – the soft, fatty mound of tissue covered with pubic hair, above the labia
• labia majora – two large, outer fleshy lips, which surround and protect the inner lips known as labia minora
• labia minora – two inner lips (may be smaller or thinner than the labia majora)
• clitoris – the main organ for sexual pleasure in females. It is located where the labia minora join at the top of the vulva. During arousal, the clitoris fills with blood and becomes erect, and touching it can lead to sexual climax (orgasm)
• Bartholin glands – two small glands near the opening of the vagina. They produce mucus to moisten (lubricate) the vagina.

The vagina

Sometimes called the birth canal, the vagina is a muscular tube about 7–10 cm long that extends from the cervix to the vulva. The vaginal opening is where menstrual blood flows out of the body during a period, sexual intercourse occurs, and a baby leaves the body.

Urethra, anus and perineum

Below the clitoris is the urethra, for passing urine. Further down is the entrance to the vagina, and behind that is the anus. The area of skin between the vagina and the anus is called the perineum.