Questions & Answers

Questions & Answers (20)

D&C Procedure after a Miscarriage

What is a D&C Procedure?
D&C, also known as dilation and curettage, is a surgical procedure often performed after a first trimester miscarriage. Dilation means to open up the cervix; curettage means to remove the contents of the uterus. Curettage may be performed by scraping the uterine wall with a curette instrument or by a suction curettage (also called vacuum aspiration), using a vacuum-type instrument.  

Is a D&C necessary after a miscarriage?
About 50% of women who miscarry do not undergo a D&C procedure. Women can safely miscarry on their own, with few problems in pregnancies that end before 10 weeks. After 10 weeks, the miscarriage is more likely to be incomplete, requiring a D&C procedure to be performed. Choosing whether to miscarry naturally (called expectant management) or to have a D&C procedure is often a personal choice, best decided after talking with your health care provider.
Some women feel comfort in going through a miscarriage in their own home, trusting their own body to do what it needs to.  Some see this as a vital part of the healing process, eliminating the question of “what if?” about the health of the pregnancy. There are also many women who miscarry who have a history of gynecological problems and don’t want to risk the possibility of any more complications occurring from having a D&C procedure done.  For most first trimester miscarriages, expectant management should be a viable option.
For some women, the emotional toll of waiting to miscarry naturally is just too unpredictable and too much to handle in an already challenging time. Healing for them may only start once the D&C procedure is done.  A D&C may be recommended for women who miscarry later than 10-12 weeks, have had any type of complications, or have any medical conditions in which emergency care could be needed.

How is a D&C procedure done?
A D&C procedure may be done as an outpatient or inpatient procedure in a hospital or other type of surgical center. A sedative is usually given first to help you relax. Most often, general anesthesia is used, but IV anesthesia or paracervical anesthesia may also be used. You should be prepared to have someone drive you home after the procedure if general or IV anesthesia is used.
1) You may receive antibiotics intravenously or orally to help prevent infection.
2)  The cervix is examined to evaluate if it is open or not. If the cervix is closed, dilators
(narrow instruments in varying sizes) will be inserted to open the cervix to allow the surgical instruments to pass through. A speculum will be placed to keep the cervix open.
3) The vacuum aspiration (also called suction curettage) procedure uses a plastic cannula (a flexible tube) attached to a suction device to remove the contents of the uterus. The cannula is approximately the diameter in millimeters as the number of weeks gestation the pregnancy is. For example, a 7mm cannula would be used for a pregnancy that is 7 weeks gestation.  The use of a curette (sharp edged loop) to scrape the lining of the uterus may also be used, but is often not necessary.  
4) The tissue removed during the procedure may be sent off to the pathology lab for testing.
5) Once the health care provider has seen that the uterus has firmed up and that the bleeding has stopped or is minimal, the speculum will be removed and you will be sent to recovery.

What are the possible risks and complications of a D&C procedure?

  • Risks associated with anesthesia such as adverse reaction to medication and breathing problems
  • Hemorrhage or heavy bleeding
  • Infection in the uterus or other pelvic organs
  • Perforation or puncture to the uterus
  • Laceration or weakening of the cervix
  • Scarring of the uterus or cervix, which may require further treatment
  • Incomplete procedure which requires another procedure to be performed

What to expect after the D&C Procedure:

Most women are discharged from the surgical center or hospital within a few hours of the procedure. If there are complications or you have other medical conditions, you may be kept longer. You will more than likely be given an antibiotic to help prevent infection and possibly some pain medication to help with the initial cramping after the procedure. Things to know about taking care of yourself at home:

  • Most women can return to normal activities within a few days, and some feel good enough to return to normal non strenuous activity within 24 hours.
  • You may experience some painful cramping initially, but this should not last longer than 24 hours.
  • Light cramping and bleeding can be expected from a few days to up to 2 weeks. Ibuprofen is usually suggested for treating cramps.
  • You should not insert anything into the vaginal area, including douche and sexual intercourse, for at least 2 weeks or until the bleeding stops.  (Your health care provider should give you specific instruction for when intercourse can resume.) 
  • Tampons should not be used until you start your next regular period, which could be anywhere from 2-6 weeks after the D&C procedure.
  • It will be unknown when ovulation will return, so once sexual intercourse is allowed, you should use a method of contraception until your health care provider says it is okay to try to get pregnant again.
  • Make sure to attend your follow up appointment.

Abnormal Pap Smears

What is a Colposcopy?

Coloposcopy is a diagnostic tool to determine the cause of abnormalities found in Pap smears. A Colposcopy is a visual examination of the cervix; it's a relatively simple and painless procedure, usually performed in your physician's office and lasting approximately 10- 15 minutes.
A Colposcopy seems much like a Pap smear; however, there a few important differences. You are positioned on the examination table as in a Pap smear but, an acetic acid (such as, common table vinegar) is placed on the cervix, causing the cervical cells to fill with water so light will not pass through them.
Your physician views your cervix through a colposcope. A colposcope is a large, electric microscope and is positioned approximately 30cm from the vagina.
A bright light on the end of the colposcope makes it possible for your physician to view your cervix.
Your physician focuses on the areas where no light passes through; he sees any abnormal cervical changes as white areas, the whiter the area, the worse the dysplasia. He also sees, abnormal blood vessel changes through the colposcope; abnormal vascular changes occur in dysplasia and the worse the vascular changes are the worse the dysplasia is.
If your physician is able to view the entire abnormal area through the Colposcope, a tissue sample or biopsy is taken from the whitest abnormal areas and sent to the lab for evaluation.
Cryosurgery or a freezing of the abnormal cells is usually performed next, making this a diagnostic/ treatment procedure in one. If your physician, is unable to view the entire abnormal area, as when the abnormal area extends inside the cervix, another procedure such as a Cone biopsy or LEEP procedure is performed.

CONE BIOPSY

Can be perfomed in your physician's office or as an out-patient procedure; a triangle of cervical tissue is removed, including the abnormal cells. May have bleeding and watery discharge following treatment. Additional Pap Smears as recommended.
LEEP PROCEDURE

Similar to Cone Biopsy; difference is in the instrument used, a loop- shaped instrument removes the abnormal area. Bleeding and discharge may occur. Follow your physician's recommendations for future Pap Smears.

Abnormal Pap Smears during pregnancy...

It is perfectly safe to have a Pap smear during pregnancy; if your Pap is abnormal, your physician may safely perform Colposcopy. Treatment procedures will usually be safely delayed until after your baby is born. Your doctor will perform additional Pap smears during your pregnancy, if he feels it necessary. Many times the birth of your baby will wash away any abnormal cervical cells. There is no risk to your baby in having an abnormal Pap smear.
Tips For Accurate Pap Smear Results:

  • Two weeks after the first day of your last menstrual cycle is the ideal time for accurrate Pap Smear results to be obtained.
  • Don't use any vaginal creams, medications, or douche for at least 72 hours prior to your appointment.
  • Sexual intercourse within 24 hours before your appointment can negatively affect your results.
  • Be sure your physician uses an accredited laboratory which hires only certified technicians and pathologists.

What can you do?
The single most important thing you can do, to prevent cancer is maintain your gynecological examinations according to the schedule determined best for you by your physician. Follow your physician's treatment recommendations and if you have any questions, ask your physician to explain.
Even if you've had a hysterectomy or no longer menstruate due to menopause, it's important to remember to keep up your schedule of yearly physical examinations.

How many women have Polycystic Ovarian Syndrome (PCOS)?

An estimated five to 10 percent of women of childbearing age have PCOS.

What causes Polycystic Ovarian Syndrome (PCOS)?

No one knows the exact cause of PCOS. Women with PCOS frequently have a mother or sister with PCOS. But there is not yet enough evidence to say there is a genetic link to this disorder. Many women with PCOS have a weight problem. So researchers are looking at the relationship between PCOS and the body’s ability to make insulin. Insulin is a hormone that regulates the change of sugar, starches, and other food into energy for the body’s use or for storage. Since some women with PCOS make too much insulin, it’s possible that the ovaries react by making too many male hormones, called androgens. This can lead to acne, excessive hair growth, weight gain, and ovulation problems.

Why do women with Polycystic Ovarian Syndrome (PCOS) have trouble with their menstrual cycle?

The ovaries are two small organs, one on each side of a woman's uterus. A woman's ovaries have follicles, which are tiny sacs filled with liquid that hold the eggs. These sacs are also called cysts. Each month about 20 eggs start to mature, but usually only one becomes dominant. As the one egg grows, the follicle accumulates fluid in it. When that egg matures, the follicle breaks open to release the egg so it can travel through the fallopian tube for fertilization. When the single egg leaves the follicle, ovulation takes place.
In women with PCOS, the ovary doesn't make all of the hormones it needs for any of the eggs to fully mature. They may start to grow and accumulate fluid. But no one egg becomes large enough. Instead, some may remain as cysts. Since no egg matures or is released, ovulation does not occur and the hormone progesterone is not made. Without progesterone, a woman’s menstrual cycle is irregular or absent. Also, the cysts produce male hormones, which continue to prevent ovulation.

What are the symptoms of Polycystic Ovarian Syndrome (PCOS)?

These are some of the symptoms of PCOS:

  • infrequent menstrual periods, no menstrual periods, and/or irregular bleeding
  • infertility or inability to get pregnant because of not ovulating
  • increased growth of hair on the face, chest, stomach, back, thumbs, or toes
  • acne, oily skin, or dandruff
  • pelvic pain
  • weight gain or obesity, usually carrying extra weight around the waist
  • type 2 diabetes
  • high cholesterol
  • high blood pressure
  • male-pattern baldness or thinning hair
  • patches of thickened and dark brown or black skin on the neck, arms, breasts, or thighs
  • skin tags, or tiny excess flaps of skin in the armpits or neck area
  • sleep apnea―excessive snoring and breathing stops at times while asleep

What tests are used to diagnose Polycystic Ovarian Syndrome (PCOS)?

There is no single test to diagnose PCOS. Your doctor will take a medical history, perform a physical exam—possibly including an ultrasound, check your hormone levels, and measure glucose, or sugar levels, in the blood. If you are producing too many male hormones, the doctor will make sure it’s from PCOS. At the physical exam the doctor will want to evaluate the areas of increased hair growth, so try to allow the natural hair growth for a few days before the visit. During a pelvic exam, the ovaries may be enlarged or swollen by the increased number of small cysts. This can be seen more easily by vaginal ultrasound, or screening, to examine the ovaries for cysts and the endometrium. The endometrium is the lining of the uterus. The uterine lining may become thicker if there has not been a regular period.

How is Polycystic Ovarian Syndrome (PCOS) treated?

Because there is no cure for PCOS, it needs to be managed to prevent problems. Treatments are based on the symptoms each patient is having and whether she wants to conceive or needs contraception. Below are descriptions of treatments used for PCOS.

  • Birth control pills. For women who don’t want to become pregnant, birth control pills can regulate menstrual cycles, reduce male hormone levels, and help to clear acne. However, the birth control pill does not cure PCOS. The menstrual cycle will become abnormal again if the pill is stopped. Women may also think about taking a pill that only has progesterone, like Provera, to regulate the menstrual cycle and prevent endometrial problems. But progesterone alone does not help reduce acne and hair growth.
  • Diabetes Medications. The medicine, Metformin, also called Glucophage, which is used to treat type 2 diabetes, also helps with PCOS symptoms. Metformin affects the way insulin regulates glucose and decreases the testosterone production. Abnormal hair growth will slow down and ovulation may return after a few months of use. These medications will not cause a person to become diabetic.
  • Fertility Medications. The main fertility problem for women with PCOS is the lack of ovulation. Even so, her husband’s sperm count should be checked and her tubes checked to make sure they are open before fertility medications are used. Clomiphene (pills) and Gonadotropins (shots) can be used to stimulate the ovary to ovulate. PCOS patients are at increased risk for multiple births when using these medications. In vitro Fertilization (IVF) is sometimes recommended to control the chance of having triplets or more. Metformin can be taken with fertility medications and helps to make PCOS women ovulate on lower doses of medication.
  • Medicine for increased hair growth or extra male hormones. If a woman is not trying to get pregnant there are some other medicines that may reduce hair growth. Spironolactone is a blood pressure medicine that has been shown to decrease the male hormone’s effect on hair. Propecia, a medicine taken by men for hair loss, is another medication that blocks this effect. Both of these medicines can affect the development of a male fetus and should not be taken if pregnancy is possible. Other non-medical treatments such as electrolysis or laser hair removal are effective at getting rid of hair. A woman with PCOS can also take hormonal treatment to keep new hair from growing.
  • Surgery. Although it is not recommended as the first course of treatment, surgery called ovarian drilling is available to induce ovulation. The doctor makes a very small incision above or below the navel, and inserts a small instrument that acts like a telescope into the abdomen. This is called laparoscopy. The doctor then punctures the ovary with a small needle carrying an electric current to destroy a small portion of the ovary. This procedure carries a risk of developing scar tissue on the ovary. This surgery can lower male hormone levels and help with ovulation. But these effects may only last a few months. This treatment doesn't help with increased hair growth and loss of scalp hair.
  • A healthy weight. Maintaining a healthy weight is another way women can help manage PCOS. Since obesity is common with PCOS, a healthy diet and physical activity help maintain a healthy weight, which will help the body lower glucose levels, use insulin more efficiently, and may help restore a normal period. Even loss of 10% of her body weight can help make a woman's cycle more regular.

How does Polycystic Ovarian Syndrome (PCOS) affect a woman while pregnant?

There appears to be a higher rate of miscarriage, gestational diabetes, pregnancy-induced high blood pressure, and premature delivery in women with PCOS. Researchers are studying how the medicine, metformin, prevents or reduces the chances of having these problems while pregnant, in addition to looking at how the drug lowers male hormone levels and limits weight gain in women who are obese when they get pregnant.

Does Polycystic Ovarian Syndrome (PCOS) put women at risk for other conditions?

Women with PCOS can be at an increased risk for developing several other conditions. Irregular menstrual periods and the absence of ovulation cause women to produce the hormone estrogen, but not the hormone progesterone. Without progesterone, which causes the endometrium to shed each month as a menstrual period, the endometrium becomes thick, which can cause heavy bleeding or irregular bleeding. Eventually, this can lead to endometrial hyperplasia or cancer. Women with PCOS are also at higher risk for diabetes, high cholesterol, high blood pressure, and heart disease. Getting the symptoms under control at an earlier age may help to reduce this risk.

FEMALE INFERTILITY

Infertility is a condition that affects approximately one out of every six couples. An infertility diagnosis is given to a couple who is unsuccessful with their attempts to get pregnant over the course of one year. When the problem exists within the female partner, it is referred to as female infertility. Female infertility factors contribute to approximately 50% of all infertility cases, and female infertility alone accounts for approximately one-third of all infertility cases.

What causes female infertility?
Female infertility usually occurs when there is a problem with ovulation, a damaged fallopian tube or uterus, or there is a problem with the cervix. Age may also contribute to fertility struggles because as women ages, her fertility decreases.
Ovulation problems may be caused by one or more of the following:

  • A hormone imbalance
  • A tumor or cyst
  • Eating disorders such as anorexia or bulimia
  • Alcohol or drug use
  • Thyroid gland problems
  • Overweight
  • Stress
  • Intense exercise causing a loss of body fat
  • Extremely short menstrual cycle

Damage to the fallopian tubes or uterus may be caused by one or more of the following:

  • Pelvic inflammatory disease
  • A previous infection
  • Polyps in the uterus
  • Endometriosis or fibroids
  • Scar tissue or adhesions
  • Chronic medical illness
  • Surgery to remove a tubal pregnancy

Abnormal cervical mucus may be the cause of your infertility. Abnormal cervical mucus may prevent the sperm from reaching the egg or make it more challenging for the sperm to penetrate the egg.

How is female infertility diagnosed?
Potential female infertility will be assessed as part of a thorough physical exam. The exam will include a medical history regarding potential factors that could contribute to infertility.
Your healthcare provider may use one or more of the following tests to assess your fertility condition:

  • A urine or blood test to check for infections or a hormone problem
  • A sample of cervical mucus and tissue to determine if ovulation is occurring

We may also use a laparoscope inserted through your abdomen to view your organs to assess for blockage, adhesions or scar tissue. An x-ray of your fallopian tubes may also be done to check for blockage. This is accomplished by an injection of blue-colored liquid through the cervix and into the fallopian tubes, which makes it easier for the technician to view the fallopian tubes through the x-ray.

How is female infertility treated?
Female infertility is most often treated by conventional methods that include one or more of the following:

  • Taking hormones to address a hormone imbalance, endometriosis, or a short menstrual cycle
  • Taking medications to stimulate ovulation
  • Taking antibiotics to remove an infection
  • Having minor surgery to remove blockage or scar tissues from the fallopian tubes, uterus, or pelvis area.

Can female infertility be prevented?
There is usually nothing you can do to prevent female infertility that is caused by genetic problems or an illness. There are things that women can do to decrease the likelihood that they experience an infertility issue:

  • Avoid sexually transmitted diseases
  • Avoid illicit drugs
  • Avoid heavy or frequent alcohol use
  • Keep good personal hygiene and health practices

When should I contact RSIA Anugerah ?
It is important to contact your healthcare provider if you experience any of the following symptoms:

  • Abnormal bleeding
  • Abdominal pain
  • Fever
  • Unusual discharge
  • Pain or discomfort during intercourse
  • Sore or itching in the vaginal area

Male Factor Infertility

Male Infertility
Infertility is a condition that affects approximately one out of every six couples. An infertility diagnosis is given to a couple who is unsuccessful with their attempts to get pregnant over the course of one year. When the problem exists within the male partner, it is referred to as male infertility. Male infertility factors contribute to approximately 50% of all infertility cases, and male infertility alone accounts for approximately one-third of all infertility cases.

Hysteroscopic

How is Diagnostic Hysteroscopy done?
Unless a woman has major medical problems,  we attach a video camera to the hysteroscopy, so our patient can also see, and then insert the hysteroscopy into the uterus under direct vision while using either saline to fill the uterus.  We then can look for fibroids, polyps, and other problems that may be causing bleeding.  This often takes about a minute or two.  The hysteroscope is removed.  A small plastic tube may be used to take a sample of the lining of the uterus.  That's it!

Hysteroscope viewing submucous myoma

Isn't this too painful to do in the office?
By being very gentle, and using local anesthesia, there is usually minimal discomfort during hysteroscopy.  Most women are able to get up and return to their normal activities immediately.   If someone is very anxious, it is possible to give a short acting narcotic intravenously.  This makes it very unlikely that the procedure will be uncomfortable. 

What is Operative Hysteroscopy?


During diagnostic hysteroscopy the hysteroscope is used just to observe the endometrial cavity (inside of the uterus.)  During operative hysteroscopy a type of hysteroscope is used that has channels in which it is possible to insert very thin instruments.  These instruments can be used to remove polyps, to cut adhesions, and do other procedures.  In many situations, operative hysteroscopy may offer an alternative to hysterectomy.

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