Smoking and Women’s Health

On No Smoking Day 2019, Consultant Gynaecologist Narendra Pisal looks at the effect of smoking on women’s health, outlining overall risk levels for gynaecological cancer and the problems associated with smoking during pregnancy and the menopause.

What is the link between smoking and gynaecological cancers?

There is a strong link between smoking and cervical, vaginal as well as vulval cancers. These cancers are caused by Human Papilloma Virus (HPV) infection and smoking is known to affect immune response to HPV. As a result, smokers are less likely to shake off this infection.

Smoking paralyses ‘cells of Langerhans’ which are responsible for carrying the ‘HPV antigen’ to the immune system which then leads to ‘antibody’ formation. As these cells are paralysed, smokers are not able to mount an immune response to Human Papilloma Virus and are more likely to have persistent infection and hence higher risk of cancer.

Some types of ovarian cancers are also more common in smokers (e.g. Mucinous ovarian cancers). The exact mechanism of how this risk increases is not known.

How much more are you likely to develop these cancers if you smoke?

According to IARC (International Agency for Research on Cancer), 21% of cervical cancer cases in the UK are caused by smoking. Risk of developing the commonest type of cervical cancer (Squamous Cell Carcinoma) is 46% higher in current smokers when compared with women who have never smoked.

Will your risk decrease after stopping smoking?

Cervical cancer is not associated with past smoking, so stopping smoking is known to reduce the risk of developing cancer. This is because the effect of tobacco on the immune system is reversed after quitting smoking.

What are the dangers of smoking while pregnant?

Smoking when pregnant is associated with increase in the risk of miscarriage, ectopic pregnancy, small baby (growth restriction), still birth, premature labour and abrution of the placenta. Smoking can also affect the newborn child by increasing risk of asthma, chest infection, cot death and poor performance at school. All in all, it is best to quit smoking as soon as possible when you are planning a pregnancy. Stopping smoking will reverse all the above risks.

Can smoking affect menopause symptoms?

It is known that smoking can affect ovarian reserve and function and can lead to early menopause. Smokers are also likely to have lower oestrogen levels. Smokers also have more menopausal symptoms such as hot flushes and poor quality of sleep. Women who smoke often don’t know that they are prone to earlier menopause and more severe menopausal symptoms. It is important to get this message out so that women have another incentive to give up smoking.

If you’re looking to quit smoking, NHS Smokefree can help. If you have any questions or concerns, feel free to contact us on 0207 10 11 700.

PHE launches ‘Cervical Screening Saves Lives’ campaign

On Tuesday 5th March, Public Health England (PHE) announced a new national campaign, ‘Cervical Screening Saves Lives’, with the aim of increasing cervical screening attendance across England. Current data shows that the number of women having their smear test has fallen to a 20-year low, with 1 in 4 eligible women (aged 25 to 64) not attending.

To tackle this, the campaign – run with the support of NHS England and charity partners like Jo’s Cervical Cancer Trust and Eve Appeal – will emphasise the importance of cervical screening via new advertising on TV and elsewhere, and a cascade of information through GP surgeries and pharmacies. It will provide practical information about making smears more comfortable and reassure those eligible that the screening is not a test for cancer, but rather pre-cancerous changes. 

Smear tests identify potentially harmful cells before they become cancerous and ensure women get the correct treatment as soon as possible. Because of this, regular screening can help stop cervical cancer before it starts. The test only takes a few minutes, and PHE research shows that once women have been screened,  8 in 10 (87%) are ‘glad they went’ and that they were ‘put at ease by the nurse or doctor doing the test’ (84%). 

Professor Anne Mackie, Director of Screening Programmes at PHE said:

‘The decline in numbers getting screened for cervical cancer is a major concern as it means millions of women are missing out on a potentially life-saving test. Two women die every day in England from cervical cancer, yet it is one of the most preventable cancers if caught early.

We want to see a future generation free of cervical cancer but we will only achieve our vision if women take up their screening invitations. This is a simple test which takes just five minutes and could save your life. It’s just not worth ignoring.’

In England, around 2,600 women are diagnosed with cervical cancer each year; it is estimated that if everyone attended regular screening 83% of these cases could be prevented. London Gynaecology wholeheartedly supports any campaign seeking to build awareness of cervical screening and prevention. ‘Cervical Screening Saves Lives’ is a helpful step towards demystifying cervical cancer and empowering more women to go to their smear test.

For further information about cervical screening, please search ‘NHS Cervical Screening’ or view the NHS Cervical Screening resources. London Gynaecology also have a number of blogs on the topic of cervical cancer prevention, including How To Make Your Smear More Comfortable and Common Cervical Health Questions. If you have any further questions, feel free to call us on 0207 10 11 700.

Discharge, Smells and Swollen lips: what every woman should know about her vagina

It can be so easy to ignore any changes or new symptoms, for fear of embarrassment and judgement. But really, we should all listen to what our bodies are saying. Although some symptoms can be unpleasant and uncomfortable to talk about, knowing the difference between a harmless change and a serious one could save you from more serious medical problems down the track. Consultant Gynaecologist Narendra Pisal talks to Glamour about the vaginal symptoms you shouldn’t ignore. Read the full article here.

What is ‘Normal’ Vaginal Discharge?

Consultant Gynaecologist Narendra Pisal explains what’s normal and what isn’t when it comes to vaginal discharge.

It is normal to get creamy whitish discharge, which can increase at certain times during the menstrual cycle. However, ‘normal’ can mean different things to different women and if your discharge has changed, you should see your GP. Excessive amount of discharge can be caused by some common and benign conditions such as cervical polyp and cervical ectropion.

Watery discharge may indicate leakage of urine or (in pregnancy) amniotic fluid.

Green discharge is often a sign of infection such as candida or bacterial vaginosis. It can also be present in presence of retained foreign body such a tampon. It is advisable to see your GP or gynaecologist promptly.

Smelly discharge can also be because of bacterial vaginosis or candida infection. The best way to get rid of the smell is to start appropriate treatment after seeing a doctor.

A sudden increase in discharge, which continues for weeks on end, means that you seek medical attention promptly. It could again be due to infections or retained tampon.

Swollen vaginal lips (labia) are often caused by severe thrush (candida / yeast) infection, or sometimes allergic reaction to sanitary products or even fabric softener. What other symptoms do you have? If there is itching and discharge, it is more likely to be thrush. If there is more redness, it may be allergic reaction. Again, it is best to see your doctor for an assessment and advice.

Happy Pancake Day!

In celebration of Pancake Day, we asked Nutritional Therapist Laura Southern for a delicious and nutritious pancake recipe that you can easily whip up at home.

Using wholemeal or spelt flour increases the fibre content of these pancakes which can support blood sugar balance – vital for anyone with hormone dysregulation. The addition of ground almonds increases the essential fat and protein content, also both necessary for hormone production and balance. Including fresh blueberries can help support the liver which is key to metabolise old circulating hormones.

Here’s the recipe:

Ingredients

• 1 cup wholemeal, spelt or gluten free flour
• 1/2 teaspoon baking powder (or bicarbonate of soda)
• 1/4 cup ground almonds
• 1 egg
• 1-1.5 cups milk (or dairy free alternative)
• 1 teaspoon cinnamon to taste

Method

• Pour the flour into a bowl and mix in the ground almonds and cinnamon.
• Pour in 1 cup milk and mix carefully with a fork to ensure no lumps. Add the egg an keep mixing til you get a smooth batter. If it’s very thick add more milk until is slightly more runny (you don’t want the mixture thin like milk, but should be pourable)
• Grease a small frying pan and heat on high. When it’s very hot start pouring in the batter to make a round pancake. Wait for bubbles to appear and then flip over. Cook for a further minute until pancake is brown on both sides. Makes about 8 thick pancakes.
• Serve with peanut or almond butter and berries. 

Enjoy!

Lunch of Champions: is it OK to Skip Breakfast?

A new study by the BMJ has found that skipping breakfast is no bad thing, especially if you are trying to lose weight. Nutritional Therapist Laura Southern discusses how to power up your lunch accordingly in this article for The Telegraph.

The Contraceptive Pill: Do I Need To Take The Break?

In light of the recent news regarding the contraceptive pill, Consultant Gynaecologist Narendra Pisal outlines how he advises his patients at London Gynaecology when it comes to the seven day break. 

In my clinical practice, I often advise women to take the pill continuously without a break. Taking the pill continuously makes it easier for women to remember. By blocking the periods completely, it also improves a lot of period-related symptoms such as heavy bleeding, pain and anaemia. Taking it continuously is also known to improve conditions such as endometriosis, adenomyosis and menorrhagia.

The seven day break makes the pill more ‘natural’ and acceptable for some women. A lot of women prefer to have a regular monthly period, as they feel reassured by it for various reasons (such as they feel it is more physiological to ‘have the blood come out’ and also a period means there is no pregnancy). Taking a break does not make the adverse effects any worse or more common (such as headaches, sleep issues).

Taking a break may cause cramping during periods and may also cause some mood swings when the hormones are withdrawn during a break. Skipping the break would improve the cramping and also the mood swings if associated with the break.

A lot of women may forget to restart the pill after the break. We also know that forgetting the pill in the first half of the cycle is more likely to lead to failure of contraception. In theory, it will be a lot easier to keep taking the pill continuously.

Why have many women been told not to skip the seven day break previously by doctors?

A lot of doctors (wrongly) believed that skipping the break would make it less effective. Skipping the break is associated with breakthrough bleeding, fear and anxiety regarding missing a pregnancy and theoretically higher risk of thromboembolism due to higher amount of hormones. This may be the reason why many doctors continue to advise taking a break.

Would a four day hormone free break as proposed instead have any advantage?

There are pill preparations available that have a four day break (Zoely) and a two day break (Qlaira). These pills are known to be associated with lighter and less painful periods. In fact Qlaira pill is also licensed as a treatment for heavy menstrual bleeding.

Many combined pill come in packets of 21. Do you think that this is set to change in the future? Do you think that the seven day break will be phased out?

There will be some preparations in the future which will provide continuous combined pills without a break. The pill has been ‘three weeks on – one week off’ for such a long time that it is unlikely to change. Continuous back to back use of the pill is outside its license terms and will continue to be off-license. The recent guidelines will make the back to back use more common but it will continue to be used in its conventional form in the majority of women.

All about Ovarian Cysts

Consultant Gynaecologist Narendra Pisal shares some information on the topic of ovarian cysts, discussing types, symptoms and treatment.

Ovarian cysts are fluid-filled cysts commonly seen within ovaries. The cysts can vary in size and range from a few millimetres to tens of centimetres. They are very common and probably most women have them at some stage of their life.

There are three common types of ovarian cysts:

• Functional ovarian cysts: These cysts are also known as follicular cysts and are common in young women. Function of ovaries is to produce eggs every month and it is not uncommon for these eggs to be retained and enlarge in size. These cysts are often self-limiting and can be monitored. Usually, these cysts will resolve spontaneously without any treatment.
• Benign ovarian cysts: These cysts are not cancerous but do not resolve spontaneously. Tumour marker (CA125) levels are often normal and surgery can be performed as a key-hole (laparoscopic) procedure. Dermoid cyst or Chocolate cysts (Endometriosis) are common benign ovarian cysts.
• Malignant ovarian cysts (ovarian cancer): These cysts are often seen in older women and the tumour marker (CA125) level may be raised. Even though ovarian cancer may be suspected on tests, it is confirmed after removal and histological analysis. Treatment is often (but not always) by open surgery. In some cases of advanced ovarian cancer, further treatment may be required after surgery in the form of chemotherapy.

Many ovarian cysts are asymptomatic but some may produce symptoms such as abdominal pain, fullness of abdomen, lump and occasionally sharp pain. Sharp pain that comes on acutely can be a sign of complications such as torsion, bleeding or rupture. Cancerous ovarian cysts in early stages may not produce any symptoms at all or the symptoms may be vague or appear unrelated. In addition to above symptoms, abdominal distension, indigestion, dyspepsia or altered bowel habits may be associated with malignant ovarian cysts. New onset of pelvic pain after the age of 50 is also a significant symptom. These symptoms often imitate irritable bowel syndrome (IBS) and you should see your GP urgently if you are older than 50 and have these symptoms.

What tests may be needed to make a diagnosis? 

An ultrasound scan (vaginal or abdominal) is used to make a diagnosis. An MRI scan may be advised to obtain further information about the nature of an ovarian cyst. CA125 blood test (also known as the tumour marker test) may be performed. This test is often raised in cancerous cysts but may also be raised in other benign conditions such as endometriosis, fibroids, infection, during monthly periods and after surgery.

How is an ovarian cyst generally treated? 

Not all ovarian cysts need removal. Functional (follicular) cysts often will resolve spontaneously. Surgery may be needed if the cysts are persistent or if there are symptoms. If there is a suspicion of cancer, urgent surgery is indicated to make a diagnosis and also as treatment.

Most of the ovarian cysts can be removed as a key-hole (laparoscopic) procedure. Three or four small (5-10mm) incisions are made on the tummy wall. Camera and special surgical instruments are then inserted to remove the cyst and healthy ovarian tissue is conserved. The cyst is then put in a plastic bag, decompressed and removed without spilling anything inside the tummy. Key-hole surgery avoids the need for a big incision and has the advantage of reduced hospital stay and quick recovery and return to normal life.

The ovary containing the cyst does not need to be removed unless the cyst is suspected to be cancerous or too large.

Are some women more susceptible? 

We don’t know exactly why but some women appear to have a tendency to develop recurrent ovarian cysts, often simple or functional cysts. It may not be always possible to prevent these ovarian cysts, but going on the contraceptive pill can help by preventing development of an ovarian follicle and cysts. We know that some genetic conditions such as presence of BRCA1&2 and family history can increase the risk of ovarian cancer. Screening with ultrasound scan and CA125 can help with early detection in these women with increased risk.

Do ovarian cysts affect fertility?

A large ovarian cyst can stop that ovary from functioning properly. Some ovarian cysts are caused by endometriosis which can be associated with reduced chance of getting pregnant. Most of the times however an ovarian cyst will not interefere with chance of ovulation and fertility.

Spotlight on British Photographer, Laura Dodsworth and her new project ‘Womanhood’

British photographer Laura Dodsworth, whose project ‘Womanhood’ features in a new C4 documentary called ‘100 Vaginas’, is using a physical taboo to open up a conversation about social and emotional taboos. Mrs Pisal talks to the Independent about there being no such thing as a ‘normal-looking’ vulva and the difference between a vulva and vagina. To read article click here.

Adenomyosis

Consultant Gynaecologist Narendra Pisal outlines the condition adenomyosis, explaining its symptoms, the impact it has on women’s lives, and the ways it can be diagnosed and treated:

Adenomyosis is a common but under-recognised condition characterised by an enlarged uterus due to infiltration of the uterine lining into the muscle wall. During menstruation, this adenomyotic tissue also swells up and bleeds within the uterine wall, which can cause severe period pain, cramps and heavy periods. The condition is often diagnosed on an ultrasound or MRI scan where an enlarged uterus is seen with one wall of the uterus thicker than the other.

Typical symptoms of adenomyosis are heavy and painful periods. Sometimes the uterus is so enlarged that a lump can be felt in the lower abdomen and can also cause pressure on the bladder and bowel causing urinary frequency and constipation. Having said that, a lot of women do not have any symptoms at all. 

Many women live with this condition without ever having a diagnosis made. A lot of women with adenomyosis have such bad periods that they have to put their life on hold for that time of the month. It affects their work and quality of life significantly. It can lead to anaemia due to heavy bleeding and lead to extreme tiredness and also affect performance at work and sports.

Treating adenomyosis

Adenomyosis can be a difficult condition to treat. Supportive treatment is often the first line of management with medication to make the periods less painful (painkillers and antispasmodic medication such as Mefenamic Acid) and to reduce the bleeding (Tranexamic Acid). Sometimes taking the minipill or the contraceptive pill back to back can also stop the periods and hence help with the symptoms. Mirena intrauterine device is also helpful in reducing the symptoms significantly. The condition also improves during and after pregnancy and after menopause.

Uterine artery embolisation (UAE) is a treatment usually reserved for fibroids but is also very effective for treating adenomyosis.  The uterine blood supply is blocked by an interventional procedure carried out through the groin blood vessels. Hysterectomy is often reserved for extreme cases where the symptoms are resistant to other forms of treatment and the family is complete.

Diagnosing adenomyosis

This condition is difficult to diagnose as the symptoms are common and affect a lot of women. A large proportion of women have heavy and painful periods and accept the symptoms as ‘normal for me’. Women don’t often know how heavy or painful their periods are supposed to be. When they do seek medical attention, often the doctors would start medical treatment to control symptoms and a scan may not be carried out or may not actually pick up the condition. 

There are many other causes of heavy and painful periods such as fibroids and endometriosis which are more commonly known. In fact, both fibroids and endometriosis often coexist with adenomyosis. Adenomyosis is also known as ‘internal’ endometriosis as the uterine lining grows inside the uterine wall where as it grows outside the uterus with endometriosis.

More doctors and women are now aware of this condition and increasing availability of ultrasound scans will lead to higher detection rate. This is good news indeed as early diagnosis will help in prompt treatment and improving the quality of life for these women.

If you are concerned about adenomyosis or heavy periods please visit your GP or contact London Gynaecology on 0207 101 1700.