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A number of medications may be used to control symptoms. NSAIDs can be used to reduce painful menstrual periods. Oral contraceptive pills may be prescribed to reduce uterine bleeding and cramps. Anemia may be treated with iron supplementation.
Levonorgestrel intrauterine devices are effective in limiting menstrual blood flow and improving other symptoms. Side effects are typically few as the levonorgestrel (a progestin) is released in low concentration locally. While most levongestrel-IUD studies concentrated on treatment of women without fibroids a few reported good results specifically for women with fibroids including a substantial regression of fibroids.
Cabergoline in a moderate and well-tolerated dose has been shown in two studies to shrink fibroids effectively. The mechanism of action responsible for how cabergoline shrinks fibroids is unclear.
Ulipristal acetate is a synthetic selective progesterone receptor modulator (SPRM) that has tentative evidence to support its use for presurgical treatment of fibroids with low side-effects. Long-term UPA-treated fibroids have shown volume reduction of about 70%. In some cases UPA alone is used to relieve symptoms without surgery.
Danazol is an effective treatment to shrink fibroids and control symptoms. Its use is limited by unpleasant side effects. Mechanism of action is thought to be antiestrogenic effects. Recent experience indicates that safety and side effect profile can be improved by more cautious dosing.
Gonadotropin-releasing hormone analogs cause temporary regression of fibroids by decreasing estrogen levels. Because of the limitations and side effects of this medication, it is rarely recommended other than for preoperative use to shrink the size of the fibroids and uterus before surgery. It is typically used for a maximum of 6 months or less because after longer use they could cause osteoporosis and other typically postmenopausal complications. The main side effects are transient postmenopausal symptoms. In many cases the fibroids will regrow after cessation of treatment, however, significant benefits may persist for much longer in some cases. Several variations are possible, such as GnRH agonists with add-back regimens intended to decrease the adverse effects of estrogen deficiency. Several add-back regimes are possible, tibolone, raloxifene, progestogens alone, estrogen alone, and combined estrogens and progestogens.
Progesterone antagonists such as mifepristone have been tested, there is evidence that it relieves some symptoms and improves quality of life but because of adverse histological changes that have been observed in several trials it can not be currently recommended outside of research setting. Fibroid growth has recurred after antiprogestin treatment was stopped.
Aromatase inhibitors have been used experimentally to reduce fibroids. The effect is believed to be due partially by lowering systemic estrogen levels and partially by inhibiting locally overexpressed aromatase in fibroids. However, fibroid growth has recurred after treatment was stopped. Experience from experimental aromatase inhibitor treatment of endometriosis indicates that aromatase inhibitors might be particularly useful in combination with a progestogenic ovulation inhibitor.
Most fibroids do not require treatment unless they are causing symptoms. After menopause fibroids shrink and it is unusual for them to cause problems.
Symptomatic uterine fibroids can be treated by:
- medication to control symptoms
- medication aimed at shrinking tumors
- ultrasound fibroid destruction
- myomectomy or radio frequency ablation
- hysterectomy
- uterine artery embolization
In those who have symptoms uterine artery embolization and surgical options have similar outcomes with respect to satisfaction.
Broadly speaking, surgical management of adenomyosis is split into two categories: uterine-sparing and non-uterine-sparing procedures. Uterine-sparing procedures are surgical operations that do not include surgical removal of the uterus. Some uterine-sparing procedures have the benefit of improving fertility or retaining the ability to carry a pregnancy to term. In contrast, some uterine-sparing procedures worsen fertility or even result in complete sterility. The impact of each procedure on a woman's fertility is of particular concern and typically guides the selection. Non-uterine-sparing procedures, by definition, include surgical removal of the uterus and consequently they will all result in complete sterility.
Adenomyosis can only be cured definitively with surgical removal of the uterus. As adenomyosis is responsive to reproductive hormones, it reasonably abates following menopause when these hormones decrease. In women in their reproductive years, adenomyosis can typically be managed with the goals to provide pain relief, to restrict progression of the process, and to reduce significant menstrual bleeding.
Severe acute bleeding, such as caused by ectopic pregnancy and post-partum hemorrhage, leads to hypovolemia (the depletion of blood from the circulation), progressing to shock. This is a medical emergency and requires hospital attendance and intravenous fluids, usually followed by blood transfusion. Once the circulating volume has been restored, investigations are performed to identify the source of bleeding and address it. Uncontrolled life-threatening bleeding may require uterine artery embolization (occlusion of the blood vessels supplying the uterus), laparotomy (surgical opening of the abdomen), occasionally leading to hysterectomy (removal of the uterus) as a last resort.
A possible complication from protracted vaginal blood loss is iron deficiency anemia, which can develop insidiously. Eliminating the cause will resolve the anemia, although some women require iron supplements or blood transfusions to improve the anemia.
Uterine fibroids can be treated with the same methods like sporadic uterine fibroids including antihormonal treatment, surgery or embolisation. Substantially elevated risk of progression to or independent development of uterine leiomyosarcoma has been reported which may influence treatment methods.
The predisposition to renal cell cancer calls for screening and, if necessary, urological management.
The skin lesions may be difficult to treat as they tend to recur after excision or destructive treatment. Drugs which affect smooth muscle contraction, such as doxazosin, nitroglycerine, nifedipine and phenoxybenzamine, may provide pain relief.
Topical lidocaine patches have been reported to decrease in severity and frequency of pain cutaneous leiomyomas.
Treatment may be delivery by caesarean section and abdominal hysterectomy if placenta accreta is diagnosed before birth. Oxytocin and antibiotics are used for post-surgical management. When there is partially separated placenta with focal accreta, best option is removal of placenta. If it is important to save the woman's uterus (for future pregnancies) then resection around the placenta may be successful. Conservative treatment can also be uterus sparing but may not be as successful and has a higher risk of complications.
Techniques include:
- Leaving the placenta in the uterus and curettage of uterus. Methotrexate has been used in this case.
- Intrauterine balloon catheterisation to compress blood vessels
- Embolisation of pelvic vessels
- Internal iliac artery ligation
- Bilateral uterine artery ligation
In cases where there is invasion of placental tissue and blood vessels into the bladder, it is treated in similar manner to abdominal pregnancy and manual placental removal is avoided. However, this may eventually need hysterectomy and/or partial cystectomy.
If the patient decides to proceed with a vaginal delivery, blood products for transfusion and an anesthesiologist are kept ready at delivery.
Usage of intrauterine device (IUD) with copper requires one IUD in each horn to be effective in case of bicornuate uterus. The same practice is generally applied when using IUD with progestogen due to lack of evidence of efficacy with only one IUD.
Evidence is lacking regarding progestogen IUD usage for menorrhagia in bicornuate uterus, but a case report showed good effect with a single IUD.
Patients with a unicornuate uterus may need special attention during pregnancy as pregnancy loss, fetal demise, premature birth, and malpresentation are more common. It is unproven that cerclage procedures are helpful.
A pregnancy in a rudimentary horn cannot be saved and needs to be removed with the horn to prevent a potentially fatal rupture of the horn and uterus.
Although it is unclear whether interventions before conception or early in pregnancy such as resection of the rudimentary horn and prophylactic cervical cerclage decidedly improve obstetrical outcomes, current practice suggests that such interventions may be helpful.
For fallopian tube obstruction, alternative medicine has been used as a form of fertility treatment. A study of the use of alternative methods showed that only a minority of infertile couples utilize such treatments. It also showed that alternative methods are more often chosen by couples who were wealthier, have not yet achieved pregnancy, or had a belief in the effectiveness of such treatments. Of the study participants, 29% used a CAM modality for treatment, 22% used acupuncture, 17% used herbal therapies like Fuyan Pill, and 1% using meditation.
Therapy is based on staging and patient condition and utilizes one or more of the following approaches.
Surgery is the mainstay of therapy if feasible involving total abdominal hysterectomy with bilateral salpingo-oophorectomy. Other approaches include radiation therapy, chemotherapy, and hormonal therapy.
Prognosis is relatively poor.
Surgical intervention depends on the extent of the individual problem. With a didelphic uterus surgery is not usually recommended.
A uterine septum can be resected in a simple out-patient procedure that combines laparoscopy and hysteroscopy. This procedure greatly decreases the rate of miscarriage for women with this anomaly.
Treatment options are rarely needed, and include exercises, a pessary, manual repositioning, and surgery.
The most important retroverted uterus treatment is done by identifying the root cause of the problem and treating it gradually. This is important as sometimes, these underlying problems can transform into something extremely challenging.
Secondly, there are some exercises which can help in this condition but usually, this does not work for severe cases and the uterus might tilt backwards again.
Laparoscopic retroverted uterus treatment is also a preferable option as this can be done easily and with fair accuracy. For any kind of help on retroverted uterus, the patient's gynecologist is the best person for initial consultation.
The preferred way of treating retroverted uterus is through highlighting and treating the underlying condition, like endometriosis, adhesions, fibroids etc.
Hormonal treatments for such underlying conditions are very common, and they tend to produce good results with time. Laparoscopic methods have also become quite common in treating retroverted uterus and they tend to be quite effective.
Other than these medical methods, there are some pelvic exercises which can help if a patient has a retroverted uterus and pregnancy is desired.
Clear diagnosis is useful to avoid unnecessary treatment and exclude more sinister diagnoses (for example, haemoptysis or pleural effusion could also indicate cancer). Overall treatment for pulmonary endometriosis is surgical, with subsegmentectomy. It is obviously important to preserve as much lung parenchyma as possible, while removing macroscopic signs of pathological tissue. Medical treatment includes gonadotropin-releasing hormone analogues, which can cause cessation of menstruation and decreased libido, as well as a 50% recurrence rate. Even in the asymptomatic, treatment is recommended to prevent possible complications listed above.
A septum can be resected with surgery. Hysteroscopic removal of a uterine septum is generally the preferred method, as the intervention is relatively minor and safe in experienced hands. A follow-up imaging study should demonstrate the removal of the septum.
Tactile cold scissor metroplasty was described as a back technique for hysteroscopic challenges that interfere with proper visualization or uterine distention
It is not considered necessary to remove a septum that has not caused problems, especially in women who are not considering pregnancy. There is controversy over whether a septum should be removed prophylactically to reduce the risk of pregnancy loss prior to a pregnancy or infertility treatment.
The uterus should be evacuated and contractions should be stimulated using intravenous oxytocin; hysterectomy (the removal of the uterus) may be needed in some cases.
Treatment of fallopian tube obstruction has traditionally been treated with fallopian tubal surgery (tuboplasty) with a goal of restoring patency to the tubes and thus possibly normal function. A common modern day method of treatment is in vitro fertilization as it is more cost-effective, less invasive, and results are immediate. Alternative methods such as manual physical therapy are also cited for the ability to open and return function to blocked fallopian tubes in some women. Treatments such as assisted reproductive technologies are used more often than surgery.
In postmenopausal bleeding, guidelines from the United States consider transvaginal ultrasonography to be an appropriate first-line procedure to identify which women are at higher risk of endometrial cancer. A cut-off threshold of 3 mm or less of endometrial thickness should be used for in women with postmenopausal bleeding in the following cases:
- Not having used hormone replacement therapy for a year or more
- Usage of continuous hormone replacement therapy consisting of both an estrogen and a progestagen
A cut-off threshold of 5 mm or less should be used for women on sequential hormone replacement therapy consisting both of an estrogen and a progestagen.
It the endometrial thickness equals the cut-off threshold or is thinner, and the ultrasonography is otherwise reassuring, no further action need be taken. Further investigations should be carried out if symptoms recur.
If the ultrasonography is not reassuring, hysteroscopy and endometrial biopsy should be performed. The biopsy may be obtained either by curettage at the same time as inpatient or outpatient hysteroscopy, or by using an endometrium sampling device such as a pipelle which can practically be done directly after the ultrasonography.
Hematometra is usually treated by surgical cervical dilation to drain the blood from the uterus. Other treatments target the underlying cause of the hematometra; for example, a hysteroscopy may be required to resect adhesions that have developed following a previous surgery. If the cause of the hematometra is unclear, a biopsy of endometrial tissue can be taken to test for the presence of a neoplasm (cancer). Antibiotics may be given as prophylaxis against the possibility of infection.
Many patients with an arcuate uterus will not experience any reproductive problems and do not require any surgery. In patients with recurrent pregnancy loss thought to be caused by an arcuate uterus hysteroscopic resection can be performed.
A review indicated the effectiveness of transdermal nitroglycerin.
Use of hormonal birth control may improve symptoms of primary dysmenorrhea. A 2009 systematic review however found limited evidence that the birth control pill, containing low doses or medium doses of oestrogen, reduces pain associated with dysmenorrhea. In addition, no differences between different birth control pill preparations were found.
Norplant and Depo-provera are also effective, since these methods often induce amenorrhea. The intrauterine system (Mirena IUD) may be useful in reducing symptoms.
Once RLP has been diagnosed, there are many ways to reduce the pain without jeopardizing the pregnancy.
- Analgesics. Acetaminophen or paracetamol is safe to take during pregnancy, thus is the most commonly prescribed pain reliever for pregnant women with RLP.
- Heat application. Applying a hot compress to the area of pain may give some relief. Hot soaks and hot baths may also help.
- Modifications in movements and position. Triggering factors that can cause RLP are sudden movements, (e.g. sitting up and down, standing up, sneezing, coughing), physical exertion, and long periods in the same resting position. A change in daily activities can help find relief and prevent worsening of the condition. Avoid sudden movements that can cause spasms of the ligament. When about to sneeze or cough, brace yourself by bending and flexing the hips to minimize the pull on the ligaments.
- Rest. Resting is one of the best remedies against RLP. When lying down, changing position slowly and regularly is recommended.
- Physical exercises Daily stretching exercise may be recommended by a gynecologist. An example of such an exercise is kneeling with hands and knees on the floor, then lowering your head to the floor, and keeping your bottom up in the air. The so-called pelvic (hip) tilt exercise also appears to help in reducing pain intensity and duration.
- Surgery. In RLP pathologies involving endometriosis and ademyosis, surgery may be necessary to perform resection of the ligament or removal cysts and myoma.
There are several methods of treatment for individuals with vaginal atresia. The first method of treatment that is recommended would be self-dilation of the vagina. A doctor may first recommend that the patient first attempts to create a vagina themselves through the process self-dilation. The self dilation technique consists of using vaginal dilators, which are small round tubes that vary in size and are similar in size and shape to tampons. Vaginal dilators may be pressed alongside the vaginal area on a regular basis in order to further open the vaginal canal. Frank's procedure is a technique that used a progressive series of vaginal dilators that are inserted into the dimple of the vagina while using pressure. This will widen any space that exists between the bladder and the rectum. Frank's procedure can be performed directly by the patient, therefore requiring no surgery or anesthesia. The procedure/technique can take months to complete, with regular compliance necessary. The overall success rate for females who use Frank's procedure is 80%. If this procedure does not work, then surgery would be the next method of treatment. Another alternative form of treatment would be surgery, or the creation of a new vagina.
Invasive hydatidiform mole, also known as invasive mole and chorioadenoma destruens is a type of neoplasia that grows into the muscular wall of the uterus. It is formed after conception (fertilization of an egg by a sperm). It may spread to other parts of the body, such as the vagina, vulva, and lung.