Experiencing a ‘Geriatric Pregnancy’: what are the Health Risks?

The Duchess of Sussex is said to be in good health, but having celebrated her 37th birthday in August, Meghan’s pregnancy announcement means she will technically be classified as an ‘older mum’. It may sound bizarre, but women over the age of 35 are considered to have a “geriatric pregnancy.” Consultant Gynaecologist Mr Pisal talks to Yahoo! News about the greater health risks associated with later pregnancy. Read the full article here. 

PCOS

Consultant Gynaecologist Miss Meg Wilson talks about polycystic ovarian syndrome (PCOS) 

Polycystic ovarian syndrome (PCOS) is a common condition caused by a hormonal imbalance from the ovaries. The name itself is quite misleading as it implies the ovaries have lots of cysts when it is in fact multiple follicles that are seen on an ultrasound scan of the ovaries. Follicles are a normal part of the ovary however in ‘polycystic ovaries’ there are more on show and this makes the ovary larger than normal. These follicles have a cyst-like appearance but aren’t cysts at all. A more accurate name would be poly-follicular ovaries!

Having polycystic ovaries on its own isn’t enough to diagnose PCOS. Clinicians use the Rotterdam criteria, developed in 2003, to make the diagnosis. Women must have at least two out of three of the following issues:

• Appearance of polycystic ovaries on ultrasound scan
• A hormonal imbalance, where the testosterone levels are high on blood tests (hyperandrogenism)
• Irregular periods

These criteria are very broad and mean that a lot of women could have a PCOS diagnosis. This was addressed by the European Society for Human Reproduction and Embryology (ESHRE) in the summer of 2018. They have tried to help guide this diagnosis further with the following recommendations:

• Previously the number of cysts that needed to be seen on a scan was only 12; this has been increased to 20 due to the advancement of ultrasound images
• Women who are within 8 years of starting their periods should not have an ultrasound scan to diagnosed PCOS. This is because young women’s ovaries often have multiple follicles and can be wrongly diagnosed

There is a wide variation in the symptoms that women with PCOS may experience, and the help they need to address these, if they need help at all. The hormone imbalance can cause women to suffer with irregular periods, weight gain, acne and excessive body hair growth. This hormone imbalance links in with the body’s ability to manage sugar and some women also have insulin resistance or even type II diabetes.

Polycystic ovaries do not function as they should in a normal monthly cycle. Their follicles remain at a similar size all the time rather than developing one ‘dominant follicle’ for release of an egg (ovulation). This means that ovulation may be less frequent and more difficult to predict if you are trying to fall pregnant. Women with PCOS and irregular ovulation may require the tablet Clomid or Letrozole to help their ovaries ovulate so they can fall pregnant. This is different to in vitro fertilisation (IVF) treatment.

While there is often a stereotype of women with PCOS as overweight, the condition affects women of all shapes and sizes. Victoria Beckham and Jules Oliver, for example, are two famous women who have been vocal about having PCOS. Currently there is no ‘cure’ for PCOS; management of the symptoms is the main course of treatment, but plenty of people do not need help managing these symptoms.

For those women who are overweight, weight management is the cornerstone of symptom management; and sometimes it is possible to reverse the hormone imbalance completely through weight loss. In overweight women, losing as little as 5% weight can mean the ovaries start ovulating again and lessens other PCOS symptoms.

Taking HRT during the Menopause

Menopause is the period in a woman’s life when menstruation ceases. In normal cases this usually occurs after the age of 45.

During this time ovarian function declines and periods become irregular, unpredictable and eventually stop. This decline in ovarian function means the decreased release of hormones oestrogen and progesterone, and this change in hormone level causes menopause symptoms such as hot flushes, night sweats, mood swings, lack of libido and vaginal dryness.

To support the body through menopause, many women choose hormone replacement therapy (HRT) which replaces the hormones that the ovaries were producing so that the symptoms are minimised.

What are the benefits of HRT? 

Apart from reversing troublesome symptoms of menopause and improving quality of life. HRT also helps with the prevention of osteoporosis (thinning of bones) and cardiovascular events such as heart attacks.

What are the different types of HRT? 

The two main hormones in HRT are oestrogen and progestogen. HRT involves either taking both of these hormones (combined HRT) or, in the case of women who have had a hysterectomy, just taking oestrogen (oestrogen-only HRT).

Are there any side effects? 

There are a number of side effects reported with HRT. These include weight gain, bloating, breast tenderness, bleeding, indigestion, and occasionally local irritation (patches). Often these side effects subside within a few weeks, but if they persist it may be advisable to change the way you are taking your HRT (e.g. moving from a tablet to a patch).

Are there any risks? 

HRT has been associated with increased risk of breast cancer, but choosing an appropriate delivery of progestogen mitigates this risk. Certain formulations of progestogen medication are associated with the lowering of this risk. In fact, using a Mirena intrauterine system (hormonal coil) to protect the endometrium may be a safer way to minimise increase in the risk of breast cancer.

Oral HRT medication is associated with increased risk of thrombosis (blood clot) but using transdermal HRT (oestrogen gel or patch) is safer in this respect. There is also a slightly increased risk of stroke but this applies more to older women with medical co-morbidities.

There is also a small increase in the risk of endometrial cancer.

How do you take HRT? 

There are several different ways that you can take HRT. Your GP or gynaecologist can help you decide which is best for you and your lifestyle.

1. Tablets: the most common way to take HRT. Daily tablets can either be oestrogen-only or combined HRT. The risk of blood clots is higher with tablets than with other forms of HRT.
2. Skin patches: these are small patches that are stuck to the skin, usually below the waist, and replaced every few days. Patches will survive the shower, bathing and swimming, and may be a better option if you don’t want to take a tablet every day. Patches may allow you to avoid some common side effects such as indigestion and they also don’t increase the risk of blood clots.
3. Oestrogen gel: a gel that is applied to the body, usually the arms or legs, daily. Similar to the patches, gel avoids an increased risk of blood clots. The gel comes in a pump pack and you will be advised as to how much you need to use. However, if you haven’t had a hysterectomy you will need to take progestogen separately to reduce your risk of endometrial cancer.
4. Implants: a pellet-like implant can be inserted under your skin and gives a gradual release of HRT over several months before needing to be replaced. Progestogen will need to be taken separately too.

When should you stop taking HRT? 

HRT should always be taken under medical supervision and should be reviewed annually. With appropriate supervision, there is no reason why HRT cannot be continued at least up to 60 years of age.

What if I don’t want to take hormones?

If you would like to support your body through menopause without HRT there are lifestyle changes you can make to aid menopause.

• A balanced diet with an appropriate amount of protein, calcium and certain food containing phytoestrogens (plant sources of oestrogen) can help. Common foods containing phytoestrogens are soya, nuts, lentils, chickpeas and oily seeds
• Stopping smoking and reducing alcohol consumption is beneficial
• Exercise, particularly aerobic and weight bearing exercise, is good for the bones and reduces the risk of osteoporosis
• Vitamin D is important for the bones and checking and maintaining optimum levels reduces the risk of osteoporosis
• Screening: breast and cervical cancer screening is important. Make sure you are up to date with your screening appointments

If you have any further questions about HRT or would like to book an appointment with one of our consultant gynaecologists, please give us a call on 0207 10 11 700.

What is PMS & Who Gets It?

Approximately 80% of women experience some symptoms before their period and these vary in nature and severity.  Mr Pisal talks to Femedic about why we get PMS what we can do to alleviate the symptoms.  Click here to read the article.

Planning on a Caesarean?

For an expectant mum, creating the right birthing plan is an important part of having a baby, but despite NICE guidelines, it’s not always possible to request a caesarean section unless the doctor has deemed it medically necessary.  Mrs Pisal talks to SheerLuxe about the reasons why some women might decide a caesarean is more suitable delivery method.  Click here to read the article.

Fibroids and Pregnancy 

Fibroids are extremely common with approximately 50% of women having fibroids in their lifetime. Fibroids are benign (non-cancerous) growths within the uterine muscle and most fibroids are small and asymptomatic. Some women are concerned that their fibroids may interfere with their ability to conceive, have a healthy pregnancy and give birth. In this article Consultant Gynaecologist, Ms Flemming, answers those concerns and discusses what can be done to optimise pregnancy outcomes.

Can fibroids affect the chances of getting pregnant?

Fortunately, in most cases fibroids don’t usually interfere with chances of getting pregnant. Most fibroids are small therefore don’t interfere with the cavity of the uterus or the fallopian tubes.

However, there are a few cases where fibroids can interfere with conception and this is largely down to the location of the fibroid. Submucous fibroids (those which encroach on the uterine cavity) can sometimes affect the process of implantation. This can lead to sub-fertility and sometimes early pregnancy loss. Fibroids in the upper corner of the uterus (known as the cornual region) can occasionally obstruct fallopian tubes and can be a cause of tubal factor subfertility. Similarly very large fibroids and an enlarged uterine cavity can be a cause of not getting pregnant.

In summary, if the fibroids are small, the uterine cavity is normal and the fallopian tubes are open (patent) there is no cause to worry.

Can fibroids interfere with pregnancy?

Fibroids usually cause no problems with pregnancy but can sometimes be associated with risks during the antenatal period, labour and postpartum. Fibroids can increase the risk of early pregnancy loss and preterm birth, especially if they are large or interfere with the uterine cavity (submucous fibroids).

Fibroids can grow in pregnancy, this may be hormonally driven. This can lead to increased discomfort and can also be associated with ‘red degeneration’, this is where the rapid increase in the size of the central area of the fibroid does not get enough blood supply and undergoes necrosis (dying). This is associated with pain and tenderness over the fibroid. Sometimes admission to hospital and rest is requested for pain relief, anti-inflammatory and supportive treatment.

Can fibroids interfere with childbirth?

The effect of fibroids on childbirth largely depends on the fibroid size and location. Fibroids in the lower part of the uterus can lead to fetal malposition such as transverse (sideways) or breech position necessitating a Caesarean Section. C-Section can sometimes be difficult and complex due to the location of the fibroids.

Post-delivery, fibroids can interfere with contraction of the uterus leading to post-partum haemorrhage. However, most small fibroids do not cause a problem.

What can be done to optimise pregnancy outcome?

A consultation with a gynaecologist and an ultrasound scan is often required to make an assessment. If the fibroids are found to be large or within the uterine cavity, further assessment or intervention may be necessary. Fibroids may be associated with anaemia and correction of iron levels may be required before embarking on pregnancy.

Surgical removal of submucous fibroids is associated with an improved pregnancy outcome and there should be no increase in risk during future pregnancy or labour. However some surgical procedures may mean that natural labour is not safe, your surgeon will be able to advise you if an elective C-Section is required.

How long should you wait after surgery to try for a baby?

If you are thinking of conceiving post fibroid removal surgery, you should discuss with your surgeon who can advise when it is safe to start trying. In general, it is wise to wait for a year post a myomectomy procedure and 3 months after a hysteroscopic procedure.

If you have any further questions or would like to book an appointment with one of our consultant gynaecologists please give us a call on 0207 10 11 700. If you would like to read more about fibroids and the possible treatment options please head to our specialist London Fibroids website.

Eating Well During Menopause

Almost all women going through menopause will get some menopause symptoms, however in 50% of women menopause symptoms are severe enough to affect quality of life. Nutritional Therapist, Lauren Southern, helps understand which nutrients can support menopause and those which should be avoided during this time.

Which nutrients support menopause & why?

• Essential Fats: essential fats are needed to synthesise hormones and neurotransmitters, as well as protect the heart, support joints and plump up skin. We get essential fats from oily fish (“smasht”- sardines, mackerel, anchovies, salmon, herring, trout) and from some plants (olives, olive oils, avocado, nuts and seeds)
• Phytoestrogens: these are special plant compounds which have a mildly oestrogenic affect, and can therefore create a slight oestrogen increase which is useful when oestrogen is on the decline. Studies have shown phytoestrogens can help prevent bone loss, boost libido and protect the heart.  Best sources are fermented soya, flax seed, oats, barley, sesame seeds, yams, and red clover.
• Calcium, Magnesium & Vitamin D: These vitamins are essential for bone protection. The decline in oestrogen due to the menopause means that bones stop being protected. Bones need calcium, vitamin D and magnesium and it’s important to obtain these from your diet, as well supplementation. High levels of calcium come from small fish bones, eg anchovies, sardines and canned salmon. Sesame seeds are also a good source – try tahini paste on your salad, or hummus. Magnesium is present in nuts, seeds, wholegrains and dark green leafy veg. Make these an integral part of your diet. Vitamin D is hard to obtain from food as our bodies synthesize it from the sun. It’s advised to supplement vitamin D daily.

Which nutrients should be avoided during menopause & why?

High sugar foods and high processed foods are best avoided. This is for a number of reasons:

• These foods provide very little nutrition, so they fill you up without giving anything supportive to the body.
• High sugar foods can play havoc with blood sugar. For hormone balance it is essential to have a balanced blood sugar. If it’s not balanced it can lead to mood swings, fatigue, excess sweating, food cravings and weight gain.
• A diet high in processed foods and sugar will also negatively impact on digestion. If digestion is not functioning optimally then it will become harder to absorb any of the essential nutrients provided from food and supplements.

Should caffeine & alcohol be avoided during menopause?

Both caffeine and alcohol can have a negative impact on blood sugar(seeabove) and can also prevent absorption of nutrients.

• Caffeine, specifically coffee can make night sweats and hot flushes worse, and the tannin in tea can prevent absorption of minerals such as iron and calcium.
• Alcohol unfortunately can also exacerbate depression and anxiety which can occur due to menopause, as well as affect sleep and cause dehydration which can negatively affect hot flushes.

For more information on menopause please visit our specialist site here. If you have any further questions or would like to book an appointment, please give us a call on 0207 10 11 700.

Your BMI & Getting Pregnant

A healthy BMI improves your chances of getting pregnant, both naturally and through IVF as extra weight can upset the balance of hormones that affect fertility, such as oestrogen and insulin. Consultant Gynaecologist Mr Pisal speaks to The Mirror about the importance of being a healthy weight when trying for a baby. Read the full article here.

What Makes Good Feminine Hygiene?

Good feminine hygiene is important for overall gynaecological health and with a wide array of products available it can difficult to know what’s best to use. In this article, Consultant Gynaecologist Mrs Pisal shares top tips for good feminine hygiene:

Tips to ensure good menstrual hygiene:

• If you use sanitary pads it is important to change them regularly
• If you use tampons ensure that they are not kept in for more than 8 hours
• Don’t forget about tampons.  As strange as it might sound it can be easy to forget about tampons We have seen women with retained tampons where they have forgotten the tampon and then presented with irregular bleeding and smelly discharge. They are at risk of developing Toxic Shock Syndrome.

“There are many feminine hygiene products on the market from soaps to wipes and sprays. Do I need these products?”

There are an increasing number of ‘feminine hygiene’ products on the market. But these products are not necessary. Mild and gentle ‘skin friendly’ soap or just water is enough to clean down below.

“Is having recurrent thrush due to a hygiene problem?”

Frequent washing of the vagina, especially with harsh soaps, will take away the good bacteria and oil from the skin and therefore can increase the risk of infections, especially thrush.

If you have any concerns about your gynaecological health, don’t hesitate to give us a call on 0207 10 11 700.

How Effective is the Coil?

Consultant Gynaecologist Miss Meg Wilson speaks to Bustle magazine about the different types of conceptive coil, their effectiveness and their other benefits. Read the full article here.