Sarah Johnson

Good evening, everyone. Welcome to our webinar on gynaecology. My name is Sarah. I’m a surgical care practitioner, and our expert presenter is Consultant Gynaecologist, Mr Abhishek Gupta.

This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so by using the Q and A icon, which is at the bottom of your screen. This can be done with or without giving your name. Please note that the session is being recorded if you do provide your name. If you would like to book a consultation, we'll provide you with contact details at the end of the session.

I’ll now hand it over to Mr Abhishek Gupta, and you'll hear from me again shortly.

Mr Abhishek Gupta

Thank you Sarah so just a brief overview of this session and that will start with me telling a bit more about who I am and we're going to discuss a common gynaecological issues and the potential investigation treatment these are the referrals which we get from patients and what kind of treatments are available at Benenden Hospital and what to expect and then one of the patients have kindly given her testimonials which also helps you to understand the pathway and how the hospital works and then what's and if you come and attend Benenden Hospital we work as a team.

So obviously I’m the Consultant or one of the Consultants here and Surgical Care Practitioner with Sarah who looks after urethral she also helps me in theatre for assisting she does your pre-op assessment goes to the procedure with you comes and sees you during the pre-operation post-op care and also does a set of follow-ups for some patients, she's also the team with one of her a few three of our other continuous care now specialists who take care of the patients with incontinence and prolapse so we work pretty much as a team here and then obviously if you have any questions we'll like to answer as much as possible the best of our abilities.

So, a bit about myself, I’m a Consultant Gynaecologist, I’ve been a Consultant for almost 11 years now. I did my specialist training in southeastern rotation and guidance, and Thomas's was the tertiary hospital for my rotation. As far as I’m concerned, I'm a Gynaecologist and also a European Gynaecologist, which deals with prolapse with my special emphasis dealing with process and incontinence, and me organically at my NHS trust. I also do laparoscopic surgeries, and I’ve done the Royal College at once training in vaginal surgery, Urogynaecology and abdominal surgery both left open laparoscopy a member of British society of European ecology and also royal college of obsession gynaecology that so that's my brief background so what are the companies refills we get in our practises here so the gynaecology referral we get is for heavy painful fields which is which is quite common as you would expect then we have reference for fibroid which may or may or may not be related with heavy pain food period but I like to quite talk to you so that you have a knowledge of what fibroids are when they need treatment when they don't need treatment and what to expect over insist is quite common one and that sometimes panic species as well when they get diagnosed with ovarian cyst polycystic ovaries they get diagnosed slightly diagnosis and there are some kind of myths as well over on polycystic ovaries and where to get information because and I would like to address that then pelvic pain which may be causing from other reasons as well which is oil system fibre uterus because they are intermittent but something called endometriosis we'll talk about pelvic inflammatory disease is secondary to infection we see less of that in in in a tiny setting here more of the pelvic infections people see is as an emergency in in NHS as emergency hospitals and I’ll touch base on menopause and I do a separate webinar because European apology issue which is important product itself is a very big subject to be covered in next half an hour or so but I’ll try to do a brief outline here but I do I have done previously a full webinar on in conferences and prolapses and that will still be available for you to view and we'll repeat it in future as well obviously so what are heavy and painful period. What is a heavy period? I think it's very difficult to quantify what is heavy for someone and not heavy for someone, so it's quite subjective. So, if you feel that your peers are affecting your quality of life because they are really heavy for your own standards and you're passing out of clothes, that means they are heavy. The other slide is that they're getting you tired. Maybe we take your blood counts, and then your haemoglobin, which is, on blood, may be coming down, but it's very subjective, and patients are the best charge of how heavy their periods are, and when you get in heavy piercing, you get referred for heavy periods.

Because we want to see how heavy and painful they are how is your previous are they regular how long they last and then we also discussed then we do a common examination because we want to see the neck of the room just to make sure that no abnormality on the neck of the room until as you had a very recent smear test let me know there is no abnormities and then examination can say what the size of the womb looks like you usually get a scan to make sure that the lining of the boom is fine and then you don't have any fibroids which are muscle mass which is a lump of muscle mass on the moon and once we rule all of this out then once the causes of the heavy periods are ruled out then usually this is then labelled as dysfunction uterine bleeding what that means is that there is no obvious pathology causing heaviness of the bleeding and that's usually is because of slight disruption at the molecular level on your womb which stops the blood flow now which prevents you stopping the blood flow in a timely fashion it can be dealt with a simple medication like chronic emic acid which helps to change that molecular level clotting mechanism on your boom and this can be prescribed by your GP and it's a non-hormonal medication which can be only taken during your periods on the days which are heavy it doesn't stop you getting pregnant so if you're planning for get pregnancy and you have a very period to rule out any pathology then you can start a trijective acid it can combine with something called mefenamic acid or other anti-inflammatories like naproxen during the period and they work in synergy together which can help together with loss of heaviness of the period and also may give you a good pain good control and again this this needs to be taken only when the days are heavy then if that doesn't work and obviously if you are not planning for pregnancy in in a recent future then you can have either then you can apply the hormones which can be added upon separate pills which can be combined or even progesterone on the bills if you have any side effects of a combined pills or you can have an implant or depo injection or you can have a Mirena coil cytogen which is a hormone containing coil the advantage of medina coil is it's a local coil so the hormone which gets secreted is secreted in a controlled fashion and it acts locally around the room so amount which comes in your bloodstream is so small that doesn't get any systemic side effects effective or for almost 80 of the patients so four and five patients are happy with the score the periods are much lighter some people do have to have a period stops and when you want to get pregnant future when the quality is removed your fertility returns back to normal very quickly so that's an advantage of the coil then if things don't work then we're talking about a surgical option which we obviously have to reserve for patients if they're if they are not contemplating pregnancy so what is ablation is a procedure where basically we have a look inside the room with the camera and then use a technique called lower shot which is at the radio frequency waves it basically burns the lining of the womb and 80 of those patients either stop the period straight away or the periods become much lighter this is good option as long as your womb is the anatomy of the womb is not disturbed because of fibroid and this is only applicable and only offered for patients who have then completed their family because after this highly unlikely you'll get pregnant though this is not contraception then hysterectomy is amazing services but we do it routinely if things above things don't work on patients and that's a cool standard which you have a hysterectomy you will not have periods myomectomy is a procedure to remove the fibroids if you're a chunky fibroids causing heavy period and this is only and this I will only recommend if you are desires of future fertility and you've got big fibroids but we'll talk about fibres in a minute so as I said the clock forward fibres in in a minute so it nicely reached out to fibroid which are fibroids are mainly the benign kind of muscular growth on the wound so if you look into this slice there are three kinds of fibroid one you will see on the top which is called which is here which is called predicated fibroid which is a fibroid on the surface which is small stock so that is the muscles of the wound that's the lining of the womb that's your neck of the room and that's the vagina that's the anatomy this fibroid here is called some mucosal which is now disturbing the lining of the room and this fibroids can cause heaviness of the period this fibroid which is in the line which is on the surface of the boom this one and this one they usually don't cause any heaviness of the period they can cause discomfort and if they're large can present with a pressure effect like pressure or like discomfort in the pelvic reason or they can also present sometimes pressure on your bladder so you may go for whatever the spirit but off not often and it may be uncomfortable for you but these are the pressure effect on the large fibre but usually they don't cause heavy periods the fibroid here which is inside the lining of the wound which is called sub mucosal this one and this one or the must on the muscle which is called intramural so one in the muscles are intramural one in the lining of the woman's submucosa and one on the surface of the womb is called sub-zero so or pedunculated so these two fibroids can cause heavy periods and they can also cause if there are big they can still cause pressure effect some mucus of fibroid can also cause you bleeding in between your periods and the pain with fibroid is usually either discomfort from pressure or sometimes when the blood supply if the fibroid gets stopped it can cause pain because of degeneration of fibroid if it's a in the cavity here which is submucosa or it is a big mass which is stopping your tubes or in preventing the embryo to get implanted here can cause fertility issues now treatment for the fibroid is depend on where the fibroids are what symptoms you are getting so you've got small fibroids for example and some people have pain in the abdomen I get referred because you had pain in the abdomen you got an ultrasound you are you are in a menopausal age group you get a scan from scan you pick up fibroids three to four centimetre intramural of sub-zero cell and then get referred because that's fibroid which is picked up incidentally now this fibroid probably fibres don't grow after you're going to menopause so they are usually during your report to age group so if you go into menopause and have small support three four of course five centimetre fibroid they usually don't cause any problem and doesn't need any treatment and fibroids are very common the non-surgical therefore fibrosis are not causing any symptoms can be treated as neurosurgical root which is observation if they're causing a bit of heaviness or period and pain you can take symptomatic treatment like what I told about transmission pain relief medication or simple analgesia Now if we are causing fluid trouble to you, then depending on where the fibroids are and what stage of reproductive age group you are, we decide what next to be done. So, if you're getting heavy periods and the fibroids are on the lining of the room, we recommend you have what is called a client cervical resection fibroid, which is TCRF. So, it's done in general anaesthetic. We put a camera through your neck of the womb inside the womb, and then we use saline to expand this area, and this we remove this fibroid with the, we're cutting it off piece by piece, like shaving the five radar This procedure is called resection fibroid. It's a day-case procedure, and you can go home on the same day. It takes a week or 10 days to recover, so it's a day-case procedure. if you have to remove the fibroid on the muscles of the womb or on the surface of the room then that's called myomectomy it's quite a major operation and it's as major as distract me if not more fibroids are quite notorious with their blood supply and once the myomectomy is done it leaves quite a significant scarring on the wound so if you ever have to have a further hysterectomy or any other procedure after my myectomy there is a quite a bit of scarring so I just I recommend myomectomies if it's a symptomatic fibroid myomectomies to be offered to patients who have not completed their family and fibroids are causing their causing problems to them if you have completed your family then my myectomies are not the best options myomectomies can be done in the laparoscopic keyhole or open keyhole biome activities are usually for a single fibroid around six seven centimetre but if you have multiple big fibroids open surgery is usually what is recommended and then hysterectomy is always a last resort to go through if the fibroids are big or they're causing trouble and you're completely family we can then think about going for hysterectomy which is a major surgeon but and as long as your womb is not really big i.e. not above from not coming up from pelvis to the tummy then most of the stack them is are done through keyhole surges however if the fibres are really big and they're distorting the anatomy completely then we'll have to resort to a traditional open technique of structuring the last option for my for fibroid treatment is called uterine nitroenbolization which is through this is a radiological technique where we put the where it's not done by Gynaecologists it's done by radiologists and we don't offer that at Panadol but some of the other places do and this where radiologists the with the control of scan they put little particles which stops the blood supply to the fibroid and it shrinks the fibroid slightly and may cause you it won't take the fibroids away it's not going to stop the fibroids completely and not all fibroids are suitable for this treatment but it measuring the fibroid and give you some relief but that's also one of the options then the next common results I get or we get is for over insist so in this diagram that's the room that's the tube which is called fallopian tube it takes the egg from the tube back to the uterus and that's the ovary that's this that's a small cyst which is shown in order this is a really small system it's called simple cyst of follicle cyst now a lot of scans if you have especially in the reproductive h group or even after that you will find a small cyst and you will not uncommonly form a small cells which particle says it's a physiological system anybody who produces an egg every cycle will form a small cyst up to five centimetre simple process is normal and we often don't have to treat it because it most of them get resolved so all you need is an interval scan in four to six months to ensure the cyst is not growing up in size and if this does grow up in size we may have to resort to treating it with a keyboard surgeon that other cysts which are common are mucinous kind of cysts which are again benign which is slightly different because that's mucine collection inside endometriomas are slightly different but tumour which is also called chocolate cyst which is sister where the lining of the womb which is called endometrium are also sometimes found in the pelvis of human being and in this it can form a system of ovary which is then like shedding your lining of the or bleeding inside the cyst which is called endometrioma endometriosis can cause pain.

And if it's symptomatic then we may have to do we will have to do a treatment and the most dangerous is endometrioma are treated by keyhole surgery either we take the cyst out and do the treatment with the keyword surgery and if you have completed your family and you are near the menopause then and if the energy is quite severe then we may talk to you about removing the ovary and endometriosis or offering is technically depending on what operation you had and what is your fertility options and various things but standard for a young patient if you put endometrioma the first treatment is do it either surgery and take the cyst out the demo system very common what is turdoid cyst as you can see produces egg and then when it produces an embryo and from embryo the whole human being developed so the ovaries have the cells which can develop them to anything and that's called germ cells so what demotists do is number exist from this little germs cells anything can develop so there is a cyst bone which can have like c sebaceous material which is like your sweat it sometimes had hairs it sometimes can't can get born and it can it can sometimes have teeth and various kind of things so anything which is from a germ cell can develop it can have in the void cyst it's boiler voices can be left but if a lot of demosis then we often offer you a laparoscopy and more of orchidual surgery and remove this cyst if the damages have gone quite big i.e. at roughly eight to nine centimetre analysis anything between seven and nine centimetre and above then we try to then offer you open surgery because it's sometimes very difficult to remove a big cyst which has got all these elements in it and clean through keyhole surgery because it can leave a lot of mess and therefore it's much easier to give a small car and take the system but anything below six and six to seven centimetre can be done laparoscopically then sometimes there's something about borderline ovarian tumours which exactly we don't know what they're going to be like so we don't know whether they have an abnormal element to it but it's not enough to call it cancer we don't know whether it is going to be going to and progress into cancelling feature or not so if you have any borderline ovarian tumour which is suspicious then we usually removed sorry and then you will need to have medium to long term follow-up to make sure that they're not coming back and last is cancer so if you have ovarian cyst or anything especially in perimenopausal and later age group after menopause and worth getting it checked because ovarian system when cancer can be quite silent and can present quite late so what are the communist investigation An ultrasound scan is quite good for most ovarian cysts. occasionally ultrasounds can when the cyst is complex way i.e. there are elements of some cystic elements some solid elements or the acceptation then we are not sure what the cyst does and then we take the help of modalities like CT scan and MRI for some of the large cysts or if the system from towards the end towards the menopausal patients and we may need to do some tumour markers which are tests and if it's a big cyst in a very early age group then we do jumps out tumour markers like alpha foetal protein and hcg that's to make sure that there are screening tests to make sure that this is nothing to be worried about and as we did as we were going through different kind of cyst I was talking about the treatment it depends on really depends on the diode assist either believe it and repeated scan and see what's going on and if it's symptomatic and it's lost sight then it needs to come out which is depending on what kind of say start the video you take it laparoscopically or open surgery.

Cystic ovaries this is this is a quite a fascinating subject because polycystic ovaries I get of I get patients coming in who are diagnosed with polycystic ovaries and it's a common kind of thought process that if you have a polycystic cover it's got a huge ovary so if you if you go back to this little diagram this is a normal ovary in patients who have polycystic ovaries you get this kind of necklace like an appearance of this polygons so you do you see the small holes which are like a small follicles or the cells so they're all x in your or release you're born with when you start menstruating every month one of these eggs will mature get ovulated and come out but when you have polycystic ovaries these eggs are not releasing they are just on the surface of the ovary but not getting released now polycystic ovaries and they have small cysts but they're only around 10 millimetre in size so they're not big therefore they don't cause any pain and they don't have any big system of research and it doesn't cost major changes in or even in terms of size and it doesn't cause pain so if anybody says I’ve got policies recoveries and I’ve got pain it doesn't happen that way now policy stick offers are scan diagnosis polycystic ovarian syndrome are two out of three features, so either they have scan features, and then, second, you may have an irregularity of the menstrual cycle, and the third feature is a high androgen level, which is the buildup of male hormone, which is testosterone, so traditionally, people who have polycystic ovaries can have a slightly high testosterone level, and two out of the three makes that as a polycystic ovarian syndrome, it's not that uncommon polycystic ovaries, almost two to 20. I mean, it's reported in a variety, but almost one in 20 women are born with polycystic ovaries.

The polycystic ovaries if are diagnosed sometimes on a scan which was done for a different reason you may not even know that you have positive ovaries because you've got regular periods you've got no problem with getting pregnant and then scan short you have quality yes you have policy cigarettes but they're not causing any problem for you and hence don't need treatment because nobody can nobody can cure polycystic ovaries and if they're not causing any problem to you it doesn't need any treatment so what are the common presentations can cause irregular periods and some people to an extreme spectrum may not have any periods as I said it political syndrome there's some these patients or this woman will have slightly high male level hormones which is called testosterone and hence may have slightly more growth a more tendency towards having male pattern of hair growth some people have and they can be slightly overweight or maybe very overweight and they may find it difficult on losing the white Some people have acne, and if you're not having regular periods, you may find it difficult to determine what the treatment is for it.

A healthy lifestyle is most important, even if you are overweight and find it difficult to lose weight. We will first and foremost ask you to consider losing weight by having other senior dietitians or clgps see anything health-related in the community. Having a healthy lifestyle means making sure you find a diet pattern, take help from things like the swimming world, whatever works for you, regular exercise, and less consumption of very high fat or carbohydrate, which will help weight loss. if your overweight is very important and without that not much can be achieved then all this theory need to be treated only depending on what symptoms is causing you so it is causing you a regularity of menstrual cycle or if it's not causing if it's causing you no periods at all then you will need three to four periods in a year to protect your lining of the womb because if you don't have any periods then constant increase hormones can make your lining up the room abnormal and hence you need something called progesterone tablet for seven days at least three to four times a year to protect your lining in the womb so that you should have three to four periods a year then for your computers are regular and you're not running for a pregnancy then you can have other oral contraceptive pill or you can have to strongly pill or admiral according for example this woman containing coil will keep regulating your lining of the room will keep supporting it up and you may get better if you have excess hair growth oily skin acne you can try a pill called a dynamic pill which has got slightly anti-endogenic effect which may help but if it continues to grow then you might have to see an endocrinologist or at some point you may have to see a dermatologist or any expert to help you with acne or a heroinism if you are finding it difficult to conceive and you have polycystic ovaries and you're not able to ovulate that is the extra not getting released and you made a further fertility treatment with a with fertility specialist and most of the time simple medication like promethean will kick start your ovaries to produce egg but if you're overweight as I said if you lose weight it also kick-starts your ovaries and occasionally you may have to give you metformin which is a medication which helps to become to regulate insulin because patients work for policy to go with higher level of resistance to insulin hormones if your policies covers if you quite want to read something on it google can give you a lot of jargon and it's very difficult I would recommend you go to a royal college of obstetrician and Gynaecologist website which is our cog website and there is a patient information leaflet we just have a search for patient information listed on polycystic recovery and on RCOG website and that's a quite a good tool for you to know about policy congress accuses that's again a common one where the lining of the womb, which is this one, is shed every cycle. It's what is all is sometimes found in your pelvis, which is called endometriosis.

So, the lining of the womb is called endometrium, shared every cycle but sometimes found outside the pearl, which is called endometriosis. Now why does it happen? Nobody knows there's so many theories, but endometriosis, we don't know why it happens. Endometriosis is only a problem in the reproductive age group. After you go into menopause, endometriosis usually doesn't cause any symptoms or problems. Endometriosis can present; some people have no symptoms. nucleus and we do keyhole surgery for some other reason and say iron because someone endures it doesn't need treatment in that case if you've got no symptoms but endometriosis cancer with quite painful heavy periods it can also present with pain during sexual intercourse it can also present pain while you're opening bowel if it's a serious.

As well, now it really depends on what symptoms you have. The investigation for endometriosis is an ultrasound scan. An ultrasound scan will only pick up a big cyst or endometrioma on the ovaries; it will not pick up the small surface endometriosis on the lining of the bone lining of the pelvis. MRI can detect several forms of endometriosis scarring with a bowel; a bowel is getting involved, but again, it doesn't pick up the tiny spots on the surface of the of inside the tummy cavity. The gold standard for picking up endometriosis is a keyhole surgery, which is laparoscopy, which is associative and done in general anaesthetic.

It's obviously a risky procedure but as any surgery there is risk involved which is roughly around one in 300 risk of any major complications and that is a gold standard way to know whether you have endometriosis or not and if you do have endometriosis majority of times you can treat dip either exciting it or endometriosis is cut out completely but if it's in a different place or it's difficult to take it out then you can burn or it's very small you can burn it off and it can come out I mean it can come back and matures it sometimes you have very severe form of endometriosis which is when your bowel is stuck your blood is stuck or if you it involves the ureter which is tube then you get into bladder in that case the treatment for the treatment is done in endometriosis centres not in Benenden because then severe endometriosis are done in a specialist unit with a combined approach with the colorectal surgeon and sometimes it involves urologists as well and not and all endometriosis needs laparoscopy if your symptoms can be managed and if you're happy to manage them with painkillers or other countries repel or other things like Mirena coil or depo injection then you can manage them and last resort for treating any heavy painful periods secondary end of it uses is a hysterectomy which does help if nothing else works on the patients pelting inflammatory disease as I said to you will be implementing disease is not often seen in our patient because it presents when it presents it presents in very acute form and patients of course severe pain and discharge or sometimes it can form abscess pelvic infection is usually this lining of the room this is ovary it goes from here and then it can form abscess or a lot of additions and this is things like chlamydia gonorrhoea and if you have a and there's usually treated with antibiotics not surgical or until unless there is analysis the adapses this form then you will need a surgery to clean the abscess because antibiotics don't work usually when that's as a form and you become quite sick this is commonly sexually transmitted problems but it can also come from a lost coil for a long time if you left the coil for a long time and you don't you forgot about it sometimes you get the pelvic infection and abscesses because of the colon but usually it can be picked up sooner and it can teach you the antibiotic for a complete cure menopause is the next issue which does affect unfortunately every woman when they  in their life lifetime not everybody will be symptomatic though some people go through menopause without having any symptoms the average age is roughly around 51 and we often diagnose men menopause with an absence of menstruation for 12 months perimenopause is a time when you are not into menopause you still have the periods but it can be variable  it may be irregular it may start getting heavier or you start getting symptoms like hot flashes and night sweats that can put a menopausal and that can last for variable time it can last from six months a year or even maybe more most of the time the time doing a blood test to confirm whether you are going to perimenopausal men is not useful or beneficial and doesn't give us any kind of in sight so usually there's no need for blood tests but if you're symptomatic then you can go for treatment and treatment depends on your symptoms your choice as well as your different health conditions If you are a very heavy smoker, if you are very high in your BMI, if you have a history of clotting the leg, or if you have a history of breast cancer, but you have a history of cancer of the lining of the womb, then your choices become quite limited. If you've got a healthier lifestyle, if you've got a normal weight, and if you don't have any other issues, which I’ve just mentioned, HRT can be started, and most of the time can be discussed with the general practitioner, and they can start, and that gives you a lot of health benefits overall, and it is shown to have a lot of health benefits.

And I strongly feel that a female's body goes through a lot of trauma and then goes to a neck of home and face in the future, a healthy lifestyle is the key, and whether you place under hormones or not have the lifestyle is the key, so you may like to start thinking about what you eat, drink, smoke, and exercise so you might have to stop smoking. Reduce your alcohol intake and optimise your weight. go for more exercises because all those are really important for your bone health your mental health as well as your physical health and obviously if you need you can start the HRT antarctica and is there are a combination of oestrogen progesterone position is only needed if you still have the womb and the whole idea of position is to protect the lining of the womb if you don't have a room you don't need progesterone oestrogen can be given through oral gel or patches whichever is useful for you can try those positions as I said is mainly for patients who are  who are have if you do if I had a hysterectomy in future then you don't need to protest one you can have only certain HRT which is probably much more safer than combining with the progesterone if you have a previous is your plot in the leg then you usually give you the patches so that it bypasses the liver and irrespective of whether you want to have a systemic HRT or not vaginal oestrogens for a patient who are in menopause and age group is really important because a lot of patients in late in in in in their life they have a lot of discomfort in the general area then they can present with drawings like a dragon sensation get symptoms of recurrent unit infection pain and having some oestrogen in the vagina is a local hormone which doesn't have it doesn't come in your bloodstream that much and therefore it's very safe and without any students can be very good and for if you get all the symptoms in the future menopause HRT only works well if you start earlier than later if you left it for a long time and then go into deeply into menopause then HRT may not help however the German registrations can be taken any time of your of your menopausal age group then one of these are touching this is this is a treatment and that's mainly for vaginal atrophy for the patients or thinness of the lining of the womb thinness of the lining of the vagina which can present the liquid UTI discomfort vagina dryness.

There is more and more evidence coming out, and there's still, the evidence is still being evaluated, but the safety profile, I think, is very safe. I don't personally do this procedure this is one of my colleague Mr Connell is the one who does this procedure he said it's an it's not painful yeah it's a probe which goes in and produces the laser and that helps to helps into the vaginal dryness and pain usually this is reserved for patients who have breast cancer and they are not able to take the vaginal oestrogen or if they have taken the damage student but the special symptoms are still posting them and then they can try this monolith attached for the vaginal symptoms and that's as I said you just put a small probe it delivers low power energy which is the laser and it stimulates the growth of collagen in new blood vessels and that's how it helps to manage the proper balance for the original mean process then as I said in continence products itself is quite a big subject but at the current process can happen with at any age group it's not only related with menopausalito it can happen in younger age group as well however it's more common for older age group purely because when we all go older our supports supporting tissues do get weaker and menopause also makes the tissues bigger so in this diagram it is a two-dimensional picture one thing you notice is the bladder which drinks water out then on the back you have a room vagina and the back passage then if the when the prolapse comes down in the middle which is the boom it's called uterine prolapse when the bladder sucks into the vagina it's called sister cell and where the bowel comes to the vagina it's called rectocele and now the commerce risk factor for this is repeated straining like chronic constipation listing heavy weights chronic cough, menopause, as I said, and so however it can give a lot of and that can cause prolapse. hysterectomy, you know, boom, prolapse. The treatment can be vaginal hysterectomy, where this is one of the treatments for collapse. However, if you have no prolapse and you have a hysterectomy, it just, does increase your chance of prolapse of the vagina in the future because, when we do extracting, we do have to cut the support structure of the womb to get the womb out there, and again, if you have a lot of overweight, it could just put pressure on the planet. Prolapse depends on your symptoms, so first and foremost, we would like you to optimise your weight, avoid lifting every weight when constipation occurs, and do little exercises. see the pelvic floor physiotherapist as I said here we have three continuous getting a specialists who does particular sizes and can help you to your symptoms as well as both for the blood retraining we talked a lot about the general institutions which can help to make your symptoms better and then there's something called original opacity which is like a ring or comes in a different size it's goes in the vagina it needs to be changed every four to six months it's not a cure for a prolapse but it's a symptomatic correction of the prolapse and it needs to be within four to six months and 30 is to 30 is the option which is we reserve for patients who are either got quite a large problems or they are symptomatic i.e. they feel the burst the quality of life is getting disturbed or it's starting to affect their organ function like difficulty empty the bladder all the power some people have to push it nothing the products back into vagina the option for prolapse option depends on if your blood is coming down here in the front which is called cystocele then we do a repair from the front so we go to the vagina open this area push the bladder back in bring the tissues together switch it up do the similar thing on the back of the vagina through this and for the boom prolapse the communist option is either doing the vagina hysterectomy or the alternative hysterectomy which is succession where we stretch the neck of the womb with a very strong ligament here called sector responsive implement or the last option is the use of the mesh and mesh values are increasingly under high vigilance restriction and we don't offer any messages here algorithm sometimes after hysterectomy your top of the vagina can come down which is called work prolapse that happens then the options are we can resist the nickel and the top of the vagina with the storm between cold sectors found us a little bit or we or alternatively the same mesh and sometimes when all the options have failed or the prolapses come back again and if you have completed and if you're not sexually active and you have no desire of having a sexual activity then sometimes there is a procedure called corporate places where we may try to close the pyjama with an orifice so that the programmes doesn't come down this is only reserved for patients who have failed the treatment and then notice any further surgical treatment in the future the products operation is usually one to two nights in hospital complete recovery takes four to six weeks and we ask you not to lift and weights in future don't get constipated people independence for exercises because prolapse can come back in future there's something to keep in mind but as I said it's a big topic in itself and I’ll cover it a bit more with my next webinar on in quantum and prolapse but my past webinars are also available for you to have a look at on our on our site 10 incontinence so incontinence blood and continence can be two types or sometimes it can be mixed one is called over activity overactive origin content is typically present with frequency urgency so your bladder is not able to hold the urine for that long so what your blood is doing is constantly doing this so it's typically it presents when you have a when you create water works often you're not able to hold much in the bladder somewhere around 50 to 150 ml and you may have to get up in the night sometimes you get typical lock and key lock and key kind of phenomena i.e. your burst into water works as soon as you put key in the in the in your door you start leaking and the sound of water can sometimes give you the same kind of effect the best the treatment for urgency around in quantum frequency lifestyle adjustment first which is main concourse is making sure you don't we try to ask you to decapitator up and access a coffee tea physical drinks alcohol are not good for bladder and then bloody training which is to train your planet to hold more and more and this has been taught you by our content in a specialist then there are medications for the bladder which is either two types one stops the bladder contraction and other medication helps to relax the one which helps to stop the contractions does give some side effects like dry mouth and constipation but if you adjust them then it helps which helps to relax the bladder which is slightly different reconstruction it's more safer in elderly age group and that doesn't give that kind of side effects if that doesn't work then we go for what is called uploaded protox so as a small camera it goes into the bladder which is called cystoscope with an injection we inject the Botox on the bladder wall what it does it relaxes the bladder it works very well but in one in 12 women sometimes it relaxes the blood is so well that you are not able to empty the blood and you may have to characterise yourself it's more horrible what it sounds but if the patients.

Then after we teach you how to catheterize yourself is actually not a big problem for most of the patients and then once they know what it involves they usually are very accommodating because the quality of life is really disturbed because of this and then if this doesn't work then there is a there's something called second modulation where we put a little transducer in your near backboard which helps to regulate the bladder it doesn't it is not done at Benenden and it's not done in most of the NHS hospital is only done in some few tertiary unit and then something called posterior tibial now with stimulation it's a mixed results of that and that's done by the specialist nurses who can stimulate bit of a tibial nerves and that may help with your bladder symptoms but it's not a first line treatment but it's just a given harm and it's mostly available on a private basis most of the places thank you stressing cotton is slightly different This is when you leak an involuntary leak when you cross knees, so that's your bladder. That's the sphincter that holds the bladder, and when you cough and sneeze, this area that's weakening your tube doesn't close, and then the water leaks. But this is common when you have to call things sneezing, lifting weight, sexual intercourse, or any high-impact exercises like trampling with kids. Uh, again, lifestyle modification is always so common. use of a permanent gel main interpreting is the last least invasive option we'll have a look inside we give your local anaesthetic injections here with the look inside the bladder we give four sites injection with perks that area up and it can it's a day case procedure so what we call is an office procedure so you can go as you can have it and go home there's no down time with it and it can be local as the procedure that's the advantages The advantage is that it is successful in 55 to 60 of the patients, and we may need to repeat that corporate suspension and abdominal string surgery. They both don't use any meshes, and our major surgeries take six to eight weeks for a couple to completely recover. It's more effective than bulking; it's got a 2; it's got 80; around 85% chance of success. 60 to 80 6 to 8 weeks of recovery period, but sometimes when you put more support on those areas, it can overcorrect the weakness, and one in ten women may find it after the operation and not be able to pass urine. You may need to be taught how to catheterize yourself until such time. Things do settle down; a majority of patients do settle down, and instead of being affected by 80 to 85 percent of the patients.

I’ll hand over at this point to Sarah.

Sarah Johnson

There's a patient testimonial, as I said in the beginning, which will tell us about how the journey of the patients is going in the hospital and may give you a bit more insight as well. So, Sarah, to you, this is a patient who came here for a hysterectomy, and she gives a very informative talk about her experiences here.

Claire Payne

I’m Claire. I had a hysterectomy.

Because I was struggling with my periods, they were very heavy and painful. I also had some fibroids, but actually, at the time of having them, it was also discovered that I had some endometriosis too.

Years of problems with my periods had now gotten to the stage where I probably had one week out of a month where I was feeling okay with the buildup to it, so I then also discovered I had PMDD, so it wasn't just PMDD; my whole mental health as well was being affected by it.

I sat down with Mr Gupta, and he was absolutely fantastic.

Pre-assessment with a fantastic nurse. She went through everything. She was so thorough. When I came in on the day, the staff in the ward were fantastic again. They just asked me if I understood what was going to happen on the day and how I was going to feel.

I had lovely nurses; they were really good to me and really looked after me. The facilities were great; I had my own room, an ensuite bathroom, a TV in the room, and everything that I needed. It was like home from home.

Recovery has been amazing, far better than I could have ever hoped for. I really expected to be at home in bed for six weeks, you know, struggling to get on with life, but life has returned to normal, and even a better normal actually now because I feel like I’ve got more energy.

I'd highly recommend using Benenden because I didn't have the waiting times other people are experiencing, but the surgery in itself was fantastic, as was the service that I wouldn't have received elsewhere.

Definitely go and speak to their GP first of all, but really just seek advice and help. Don't suffer in silence, because I think too often, we are told that it's something else, there's nothing wrong, or it's normal, but definitely get some help with it as early as you can.

Sarah Johnson

So, I’m Sarah, and I’m a Surgical Care Practitioner who works with the gynaecology team here at Benenden. I originally trained in the 1980s, and my favourite ward was the Garland award. I also enjoyed working in theatre, so for me, I now have the dream job working with gynaecology patients and assisting in theatre. This enabled me to complete a degree as well, so I’ve furthered my education, which has also been of great benefit to me.

This just gives you an overview of my role. I triage most of the guardian referrals that we receive at the hospital and make sure patients see the right Consultant. I see patients before their surgery for pre-op assessment, and you know, hopefully I see as many as I can. We have a great team that sees the ones that I can't, and I visit patients on the board with Consultants before their operations and then in the assistant theatre with the surgery itself. Hopefully, I get a chance to visit the patients on the ward post-op before they go home, make sure they understand what their operations involved, and answer any questions some patients may have. I do a telephone follow-up, and other parts of my role involve helping out in our ambulatory care unit, where we do hysteroscopies and cystoscopies that's checking inside the womb and also checking in the size of the bladder, and I also have sort of admin-related jobs like checking the theatre list orders, answering any patient queries, and that sort of thing.

We'll now take some questions, and the first one is that treatment for fibroids hasn't worked for me, and I’m interested in a hysterectomy. If I had a consultation, would there be a period where I can go away and decide to go ahead or not?

Mr Abhishek Gupta

Fibroids and you've tried and tried the ways treatment hasn't worked it's like them is an option and it really depends on it when once we do a consultation with you then you will be counselled about the option and also we'll discuss about hysterectomy and as I said most of the distract me fibroids until the big one can be done through keyword surgery which is a laparoscopic hysterectomy but obviously we will go through pros and cons and when you come to see us in the clinic we explain all the pros and cons and if you have any previous surgeries like previous season sections or previous cut in the tummy or previous infection and obviously or severe endometriosis then obviously it makes you go into higher risk if you didn't have any previous major surgeries then you are still complications can happen on any and during any operation but that doesn't make you relatively on that high risk pathway so we'll go through pros and cons discuss everything with you and then we do provide you with patient information leaflets to read and if then you need to have a bit of time to think about your options and come for a follow-up or do a telephone consideration obviously that that that will be always on I mean if you need more time then that's absolutely and yes as long as you have full understanding as well as your informed and you make your decision on well and after processing the information and you will inform that's the right thing to do for a patient and a doctor and that's time we need to go through and proceed for operation but yeah absolutely you will have to be well informed with your choices as well as what risk benefit is pertaining to you yourself and someone's generate but that is important for being specific for some patients.

Sarah Johnson

Next question, can fibroids return after treatment?

Mr Abhishek Gupta

Yes, fibroids can come back after treatment because, they're mostly what we know of fibroids; they are hormonally linked; they can come after taking them out, and usually fibroids, and that will only happen if you're in a triple active age group. Once you go into menopause, the fibroids should not come back, and if they do come back or are increasing in size, then we'll have to be suspicious. The majority of fibres are benign v3; that's a benign growth, but if they're coming back after menopause and they're growing up, then we have to be suspicious.

Sarah Johnson

Next question, my job involves standing for most of the day after a hysterectomy. When would you say I could return to work?

Mr Abhishek Gupta

So usually laparoscopic hysterectomy has got slightly quicker recovery open hysterectomy takes a bit of time which are ostectomies again if you're suitable they have a really quick recovery but ballpoint figure is six to eight weeks but it really depends on the individuals as you sat very lightly it depends on what your jobs are so if your job is quite heavy and quite physical most of the most of the healing has taken place in eight weeks’ time so I wouldn't expect anything going wrong after eight weeks however you may struggle because of scarring and going through a major operation and that's the best time when you have to face yourself into the work rather than going straight into a very heavy lifting and working long hours on your feet but the best person then to have the assessment is your manager and your occupational health because what your job involves they know the best what your job involves but usually all the healing has taken place in six to eight weeks’ time and after that it's just a matter of how when you feel recovering from major surgery regarding the specific work you do.

Sarah Johnson

Next question, I have a bulge in my vagina. I’m waiting for an appointment with a Gynaecologist. I'm not sure what's wrong with me yet. Is it safe for me to still do yoga Pilates and swimming?

Mr Abhishek Gupta

Yeah you've body the vagina but you're describing is probably maybe a product that you have and while you're waiting to be seen if you want to do yoga Pilates swimming that absolutely fine and probably good for you it should also only thing which I would like to say that you should avoid sleeping heavy weights and constipation apart from that you can pretty much do anything which is your day-to-day life and some people also come and ask me whether I’ve got a prolapse well intercourse can harm me its answer is no intercourse will not harming yoga will not it will be in fact good for you and Pilates will be good for you because score muscles but if you are taking but if you are with an instructor and you take you're doing a classes say spin classes or anything else it's worth mentioning it to instructor that you're under investigation for them and that's to avoid the high impact kind of exercises.

Sarah Johnson

What do you do for clitoral cysts deeper inside? Also, do you treat lichen sclerosis?

Mr Abhishek Gupta

Yeah so I’ll talk about chemical system in a minute if you it's a critical assist which is painful then we can take it out but it's a very tricky area to have a cyst and if because it's a very sensitive part of the skin yeah sometimes local anaesthetic doesn't work in general aesthetic may be required to take it out it's just can be taken out but you will always counsel you for scarring and sensory changes or sometimes you might find that it is because it's a very sensitive area of the body it can give you some sensory disturbance or neuro or  some nerve kind of changes and after the cyst is removed but majority of patients are okay but that is a standard counselling because we don't know how much of once that cyst is taken out and the scarring will affect the sensation in that area so that will be the counselling second likely scores is Yes, we do diagnosis as well as treatment. Polo sclerosis, I mean, for today we do the bubble biopsy to confirm the lichen sclerosis in a military care unit here in the local anaesthetic, which is a little biopsy from the skin that goes to the lab to be looked at, and we do treatment for lichen sclerosis if the treatment we do.

Steroid cream as well as hormones Most of the patients will work very well. If you find that it's not working well, then we do. We have our onward dermatologists here who are quite good. We work in quite a good partnership, and we can always take help from each other if it doesn't get resolved.

Sarah Johnson

The next question is my daughter has issues with the regular heavy leading while on the progesterone-only pill. She also has thrush regularly and has been treated for pelvic inflammatory disease. Her GP seems reluctant to change her pill and just keeps doing swabs. Is there anything you could do to help, and if you can, what should we ask her GP to refer her for?

Mr Abhishek Gupta

That's one of the reasons for referral that's important and then once and I don't know what age your daughter is because and we only see adult patients who are 18 years and above in in and if you will get an ultrasound scan to make sure there's lining of the movement and there's no fibroid or anything else we may have to examine to see what the necro dome is doing and see whether there's anything else is causing up and then we can change and if the pelvic inflammatory disease has been treated then we can change from progesterone appear which itself can cause a regular bleeding and spotting to a combined pill or a Mirena coil  and sometimes you may need to have a look inside the room with a little camera it's called hysteroscopy the evaluative lining of the boom so you need investigation and then depending on what we see in the investigation if there's no pathology treatment then we will change voice around April to other combine all contents of people or a mineral coil and that may be more suitable than just a position rifle for your daughter.

Sarah Johnson

Thank you if you would like to discuss or book your consultation. Our Private Patient’s team can take your call between eight o'clock in the morning and six o'clock in the evening, Monday to Friday, using a number on screen. We are offering a discount for joining this session for seven days, and with the terms displayed, you'll receive a short survey. I'd be grateful if you could spare a few minutes to let us have your feedback. Our next webinar is on knee replacement surgery. You can visit our website to sign up if you're interested. On behalf of Mr Abhishek Gupta and our expert team at Benenden Hospital, I'd like to say thank you for joining us today. We hope to hear from you very soon.