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 age-ing process. In some cases, there may be a genetic weakness of the supportive tissues.

Prolapse of the uterus can cause an uncomfortable dragging sen-sation 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 vagi-na or uterus. Different types of pessary are available: ring pessary with or without support, gellhorn pessary and a cube pessaryare 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 pessariesare made from silicone, a soft non-absorbant material that posesno 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 thereforeless suitable for longer term use. The gellhorn pessary is often used for more serious degrees of prolapse and this type of pessary 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 pessaryif it is correctly placed. If you experience significant painor 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 estrogen 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 estrogen to improve the vaginal skin, making it healthier. Your doctor will discuss the possible indications for the use of estrogens and the consequences of use. For more information on vaginal estrogen treatment read our leaflet entitled Low-Dose Vaginal Estrogen Therapy.

A copper IUD is a small device with a fine copper wire wrapped around a plastic frame. It’s placed inside the uterus to prevent pregnancy. A fine nylon thread is attached to the IUD - the thread comes out through the cervix into the top end of the vagina. There are two types of copper IUDs available in Australia - one lasts for 5 years and the other for 10 years.

The IUD is placed inside your uterus by a doctor or nurse.The copper IUD:

• is toxic to the egg and sperm which stops sperm from fertilising the egg
• slows the transport of the egg to delay chance of sperm and egg meeting
• changes the lining of the uterus to make it unable to support a fertilised egg

• most women who want a reliable, long-term contraceptive
• women who haven’t had a pregnancy, have completed their families, or are spacing their pregnancies
• women who are breastfeeding
• women who cannot, or do not want to, use hormonal contraception because of medical conditions or personal preference

You should not use the copper IUD if:

• you think you might be pregnant
• you have had a recent infection called pelvic inflammatory disease (PID)
• you have unusual bleeding from your vagina
• you have Wilson’s disease or you are allergic to copper

It is important to talk to your doctor before deciding to use the copper IUD if:

• you have painful or heavy long-lasting periods
• you have anaemia (not enough iron in your blood)
• you have had a recent sexually transmissible infection (STI)
• you have fibroids or other conditions that change the shape of your uterus
• you have had problems in the past with an IUD (for instance it has come out by itself)
• you are unable to have a follow-up check-up after the IUD is put in

• It’s very effective
• It can stay in place for 5 or 10 years depending on which one you choose
• The initial cost of a coper IUD is more than for other methods, but it lasts for 5 or 10 years so it works out to be a reasonable price
• It does not contain hormones so it has no hormonal side-effects
• Your fertility goes back to normal straight away when you take it out
• It can be used as emergency contraception if it is put in up to 5 days after unprotected sex.

• It doesn’t protect against sexually transmissible infections (STIs)
• It requires a procedure to be put in and removed from the uterus; putting it in can be uncomfortable
• When the IUD is put in there is a small chance of:
• difficulty inserting the IUD
• damage to the wall of the uterus (perforation)
• infection
• It can sometimes come out by itself
• Your periods can be heavier and last longer
• You can have some irregular spot bleeding in the first few months

Only a specially trained doctor or nurse can put in an IUD.You may need to make two visits.

• the doctor or nurse will ask questions about your health
• you might have a vaginal examination, a cervical screening test or a test for infection
• putting the IUD in takes about 10 minutes - you will be at the clinic for about 1 hour
• you may find it uncomfortable or painful and some women feel faint
• you can have a local anaesthetic
• some women have the IUD inserted under sedation – not all clinics provide this

After your copper IUD is put in:

• you may have cramps and bleeding or spotting in the first few days - you can take paracetamol or ibuprofen or use a heat pack. If cramps, spotting or pain last more than a few days, see your doctor
• avoid sex, tampons, swimming and baths for 2 days to reduce the risk of infection
• go back for a check-up 4 to 6 weeks after the IUD is put in
• check the IUD threads each month after your period to make sure the IUD is still in the right place - your doctor or nurse will show you how to do this

Things to remember with your copper IUD:

• check the threads each month after your period to make sure the IUD is still in the right place
• if you are worried you could be pregnant, have a pregnancy test – this includes if your period is more than a week overdue or you have a change in your bleeding pattern
• if you have any unusual symptoms (discharge from your vagina, pain low in your tummy or deep pain during sex) see your doctor straight away
• if you or your partner have a new sexual partner, use a condom every time until you both have been checked for STIs
• keep a record of the date to take out your IUD - it shouldn’t stay in for longer than the recommended time

The copper IUD can stay in place for 5 or 10 years,depending on the type you choose. If you are aged 40 years or more when it is put in your doctor may advise you that it can be kept in place until menopause. If you want to get pregnant or you no longer want the IUD it can be taken out earlier. Your doctor or Family Planning NSW clinic can take it out. The doctor or nurse uses a special instrument to remove the IUD by pulling on the threads. It only takes a couple of minutes. Some women find it a little uncomfortable and some do not feel much at all. If you want another copper IUD, the old one can be taken out and the new one put in at the same time.

The hormonal intrauterine device (IUD) is a small ‘T- shaped’ plastic device. It slowly releases a hormone (progestogen) into your uterus (womb). Progestogen is similar to the hormone produced by the ovaries. It is sold as Mirena, Kyleena, skyla in Australia.

It is more than 99% effective at preventing pregnancy and can last for up to five years.

The hormonal IUD might not work if:

• It falls out (remember to check the strings regularly)
• Goes into the wrong position
• It is left in for longer than 5 years

The hormonal IUD is inserted inside the uterus (womb) by a trained doctor or nurse.

It has a fine nylon string attached to it which comes out through the cervix (opening to the uterus/womb). If you feel high up inside your vagina, you can check that the string is there and know the IUD is still in place. This string cannot be seen and it does not hang out of the vagina.

The hormonal IUD works by stopping the sperm and egg meeting and thickening the fluid around the cervix (opening to the uterus/womb). This helps to prevent sperm from entering.

The hormonal IUD also works by changing the lining of the uterus/womb. This makes it difficult for a fertilised egg to stick to the lining to start a pregnancy.Sometimes the hormonal IUD can also stop the ovaries from releasing an egg.

Sometimes the hormonal IUD can also stop the ovaries from releasing an egg.When it is first inserted (put in) it can take up to seven days to start working

Your doctor will write you a script and you can get the hormonal IUD from your pharmacy. You will need to return to the clinic to have the IUD inserted. If you don't have a Medicare card it will be more expensive. It will be cheaper if you have a healthcare card.

• It is an extremely effective method of contraception
• Once it’s inserted (put in) you can forget about it for 5 years
• It can last up to 5years
• Most users have no vaginal bleeding at all or a light regular period
• Periods may be less painful
• No medications stop it from working
• It is another choice if you have difficulty taking the hormone oestrogen. ’The Pill’ (combined pill) and vaginal ring contains oestrogen and progestogen. The hormonal IUD only contains progestogen.
• You can use it while breast feeding
• It is easy to remove
• Once removed your fertility quickly returns to normal

• When it is first inserted some users have period type cramping that usually settles after a few daysWhen it is first inserted some users have period type cramping that usually settles after a few days
• Your vaginal bleeding pattern/period will change. Spotting or frequent bleeding is common in the first three to six months. By six months around 95% of users will have a light regular period or no bleeding at all (this is not harmful to the body).
• Sometimes the IUD can fall out. This is more common in the first 3 months of it being inserted.

Possible side effects for a small number of users can include:

• Sore/ tender breasts
• Headaches
• Changes to your skin
• Mood changes

These side effects nearly always settle with time. It has not been shown to cause weight gain.

• In about 1 in 500 users, the doctor or nurse makes a small hole in the wall of the uterus (womb) while inserting the IUD. The IUD can move through the hole and sit in the wrong place. You would then need keyhole surgery to have it removed.
• Around 1 in 300 users get an infection when the IUD is first inserted. This is usually successfully treated with antibiotics.
• It is very unlikely to get pregnant when using the hormonal IUD. If you do get pregnant with a hormonal IUD, there is a higher chance of ectopic pregnancy. This means that the pregnancy may settle in the fallopian tubes (pathway of the egg to uterus).

• Been treated for breast cancer
• A uterus (womb) that is not the usual shape seen
• Have severe liver disease

If you can't feel the IUD string, use condoms until a doctor or nurse confirms the IUD is in the right place. If you have had unprotected sex in the five days before you notice the string missing, you might need emergency contraception.

Once the hormonal IUD is in for more than five years, use condoms until you can have it replaced.

It is important that you see a doctor or nurse as soon as possible and have the IUD removed. The doctor or nurse will also need to rule out a pregnancy in your fallopian tubes. If the hormonal IUD is removed, you can continue the pregnancy or have an abortion. If it cannot be removed and you continue the pregnancy, there is a high risk of losing the pregnancy.

The hormonal IUD can be inserted straight after you give birth. If not inserted straight after you give birth then you need to wait at least four weeks later. The hormonal IUD is safe to use if you are breastfeeding.

The hormonal IUD can be removed at any time by a doctor or a nurse. Your fertility will quickly return.

• The hormonal IUD does not protect you from sexually transmissible infections(STIs).
• It is good to write down the date or enter that date into your phone when you had the IUD. You will need to make sure it is taken out before it expires (up to five years after being inserted).
• Your partner might be able to feel your IUD string during sex, but it rarely causes them discomfort.
• The hormonal IUD is one of many types of contraception.See other options.

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, neurofen 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.