8.(25-26) Gynecologic Surgery and Uterine/Vaginal Bleeding

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Update 29 Aug. 2021
  Scroll down for chapter 26 on gynecologic surgery.
25. Vaginal Bleeding and/or None -

The bleeding is from uterus cavity or cervix (uterus entrance/exit in vagina) or from vagina. Bleeding cyclically (menstruation-connected or ovulation mid cycle) is from uterus lining. Bleeding from cervix is noted immediately after sex; and from vulva-vagina in youth due to torn hymen; or, in older age, from cancer.

   Appearance of vaginal discharge tells much: brown or black means old blood from retained pregnancy or abortion, or from polyp; a bright red means rapid arterial bleeding. Clot is sign of heavier than normal menstrual bleeding as from fibroid tumor.

   Ovulation bleeding, seen at mid-cycle, is brief and light and mixed with mucus. It will coincide with rise in basal body temperature (BBT). It is normal but some women never see it.

When menstruation is late, if possibility exists, ask “Pregnant?” and do  the test. If pregnant, the daily basal body temperature (BBT) should show continued temperature elevation. A vaginal exam can be reassuring for not pregnant by showing blood. If you see clear mucus dripping from cervix and out of vulva and staining pants in the week midway between your menses, it means no pregnancy unless conception coitus that day. A missed period without pregnancy is due in to stress, especially fasting or weight-loss diet.

Abnormally irregular light, heavy or sometimes missing the menses is frequent in adolescence, teenage and early 20's women and also in pre menopause due to missed ovulation. Especially in slim girls. It could be lasting long or normal duration with clot or flooding. Nothing to do about it unless it is too heavy in which case, consult University-HMO gynecology. In age 35 or older, suspect fibroid tumor in uterus and get gynecology exam with ultrasound and a Babes/Pap smear (The smear for cervical cancer development, commonly called "Pap" smear should be now referred to as "Babes/Pap smear" to honor the actual inventor of the Pap smear, the Rumanian scientist, Dr Aurel Babes.) and biopsy to rule out cancer of cervix or of uterine lining.

Do not rush to get a Dilatation and Curettage (D&C) or Hysteroscopy operation in hospital just because you have abnormal vaginal bleeding. Use the above info and if the bleeding simply seems to be hormonal missing ovulation or stress, then relax. But if worried, get endometrial biopsy with ultrasound scan in University-HMO, and if the pathology report is hormonal, then relax and it should go away with time.

26. Gynecologic Surgery

Reasons for hysterectomy (surgical removal of uterus): 1) cancer or pre-cancer; 2) a hernia into vagina; 3) endometriosis with pain; 4) Pelvic Inflammatory Disease, severe; 5) fibroid tumor with symptom (Fibroids may cause hemorrhage, menstrual pain, unsightly abdominal swelling, blockage of rectum or bladder outlet by pressure.); and, 6) controversially, to assist hormonal anti-aging treatment of menopause.

Advantage of being without a uterus: Not having uterus will end regular or unpredictable blood loss and it prevents future menstruation, pregnancy and uterine cancers; and it makes hormone treatment safer and simpler. After childbearing is finished, the uterus serves no purpose and is a cause of troubles from blood loss, tumor, low abdominal pain, bowel and bladder dysfunction, and cancer.

Reason to keep one’s uterus: It avoids risks, cost and inconveniences of major abdominal surgery or one may have the desire for one’s own uterine pregnancy even into old age by In Vitro Fertilization and/or the uterus carrying one's own or another person's embryo.
   That being said, and all other things being equal, it is preferable to keep one's uterus assuming healthy normality.

Hysterectomy is either complete (total hysterectomy, which normally includes uterine tubes and may include one or both ovaries) or incomplete (supra-cervical hysterectomy, in which the cervical stump is left behind in vagina). Also to be mentioned is myomectomy, removal of fibroid tumor from uterine wall, leaving remainder of uterus intact, an operation that should only be for symptomatic fibroid causing infertility in a woman who wishes to try for a uterine pregnancy. There is also radical hysterectomy for locally spread cancer; it involves dissection to remove lymph nodes and wide cuff of border tissue including tubes and ovaries and has high complication rate but may cure the cancer at properly staged point.

   Total hysterectomy is either done abdominal (TAH) or vaginal (VH). The vaginal approach is popular with women, such as strippers and actresses, who do not like abdominal scar. Also, it may be indicated if reason for surgery is hernia of vagina, bladder, and rectum. It takes a higher degree of skill and more experience than TAH; so, if you are requesting it, be well satisfied your surgeon has done hundreds of VH and still does at least 2 or 3 a week. The VH should not be done for overly enlarged uterus, with adhesion, or for upper (endometrial) uterine cancer surgery.

   In abdominal surgery, a ‘bikini’ (short horizontal supra-pubic) incision can be done except in cases of overly enlarged organ or adhesion.

   Included in uterus surgery is cervical cone biopsy, an ice-cream-cone-shaped excision of part of cervix that removes external cervical canal and surroundings. It is done via vagina for diagnosis and as part of staging of cervical cancer. It may be curative in early cervical cancer. Pregnancy remains possible after cone biopsy but may need cesarean section.
In the past, these gynecologic surgeries were done by laparotomy (scalpel knife incision like major abdominal surgery) but now in 2021 the gynecologic abdominal surgeries are done by laparoscopy (very small incision and passage of operative telescope through which the surgery is done). A laparoscopy may easily become a laparotomy if the surgeon thinks it is necessary because of too large tumor or adhesion)

   Presently, intra-operative laser is being used much for vaginal, cervical and intra-uterine operations via hysteroscope and intra abdominal operations via laparoscope. If you opt for laser surgery, get it done in a University-HMO to be sure of good quality, correct indication and proper necessity.
   A nonsurgical treatment for bleeding fibroids of uterus is leuprorelin that works like gonadotropin-releasing hormone and interrupts the estrogen hormonal cycle and stops uterine bleeding. It is a temporary treatment and also for younger women who may want to preserve childbearing despite having fibroid uterus. I have no experience with it.

Recovery from hysterectomy may normally take up to 3 months. A complete recovery should be expected after 6 months. Removal of uterus alone should not affect sexual desire, which depends on ovarian hormone and lifestyle. But poor surgical technique may leave a raw irritated vaginal stump that can interfere with sexual relations. 

Oophorectomy is removal of ovary. Technically it is simple; clamp, tie, and cut. To remove both ovaries in a still menstruating woman will cause acute, severe menopause relieved only by estrogenic hormone therapy. Menstruation will be stopped and fertility lost. (A woman without ovary but with uterus may be a surrogate to gestate an extra-uterine fertilized embryo, which could be an embryo from her ovary before it was removed)

   After menopause, the ovaries may continue to produce significant E2 hormone and can delay or lighten symptom of menopause without causing menstruation. In such case removal of both ovaries after age 50 could result in worsening menopause symptom. This can be determined by E2 blood test before ovaries removal. One ovary is enough to allow a woman to be fertile, have menses, and delay menopause. Request right ovary removal in single-side oophorectomy to prevent confusion in later appendicitis

   Reasons for oophorectomy are ovarian cancer, pelvic inflammatory disease (PID) involving the ovary, endometriosis, and twisted cyst or benign tumor. At times, an ovary must be removed with tube in ruptured-tube ectopic pregnancy. But the most controversial and difficult decision is whether to remove both ovaries with uterus in a hysterectomy being done for uterine indication? A compromise position is to at least remove one ovary. It is estimated 10% of ovaries left behind will need surgery for cyst, benign tumor or cancer. So as the German’s say, “Besser aus!”

   Single ovarian cyst or tumor may often be ‘shelled out’ of capsule and the ovary preserved.

   Uterus tube surgery, excluding emergency ectopic pregnancy, is only done to restore fertility by either freeing adhesion or, if tubes, blocked, attempting to re-establish tube opening. The operation has a 5 to 20% success rate, depending upon the pathology and the surgeon. The pregnancy that follows may be ectopic. Today with much experience in extra-uterine fertilization and re-implantation of embryo, an option for a tube-obstructed infertile woman is in-vitro fertilization of her own egg with husband or other donor semen and re-implantation into her own or surrogate uterus.

 END CHAPTER. To read next now, click 8.27 Cloning Explained Exactly/Pregnancy Preventi...