Q&A with BMI Healthcare gynaecologists

BMI Gynaecologists 

A panel of experts answered your questions on women's health issues, including difficulty conceiving and menopause.  

The experts included consultant gynaecologists Robert MacDermott, Alvan Priddy, Tom Farrell, Sangeeta Das, Gabrielle Downey, consultant gynaecologist and obstetrician Parjit Bhattacharjee, and consultant obstetrician and gynaecologist Ami Shukla. 

The experts' answers are based solely on the information the Mumsnetter has given and it is not a clinical diagnosis - it is intended as guidance only. If you have any concerns about your health, do seek advice from your GP.


Problems conceiving

Q. HesterShaw: We have been trying to conceive for four years, since I was 34. We have never had a positive pregnancy test, despite my husband's SA being very good and everything with me apparently being fine, except now I have low AMH. Surely my AMH wasn't as low when we started trying four years ago? What else could be wrong? How can it be so easy for some people to conceive and impossible for others? Surely a diagnosis of unexplained infertility is not an explanation.

A. Mr Bhattacharjee: I do agree with you that using the word 'unexplained' while trying to explain a cause for infertility does cause confusion. It only means that no plausible cause could be found based on the necessary investigations.

I presume you and your partner have had all relevant investigations. It is difficult to conjecture what your AMH could have been four years ago. However, since you are 38 now and have been trying for a relatively long duration, ideally you should consider assisted conception, particularly because of your AMH levels.

As for your last question, all of us are different. Some women are simply born with low ovarian reserves or they decrease due to other extraneous reasons.

Q. Pickofthepops: We have been trying to have a sibling for our five year old but we haven't had any luck. Here is an overview of my medical history: I am 39 years old. My diet is OK. I am trying to cut down caffeine (I have a coffee each day), plus one unit alcohol a day. I take Zita West multivitamins. I know that I don't drink enough water. (Could dehydration hamper TTC?) I walk for an hour each day. 

I have regular periods with a 29-day cycle, albeit they're quite light and I don't 'feel' ovulation like I used to. The Clearblue monitor shows ovulation around day 14. I only get a little EWCM around days 8-11, but I get a lot of PMT in the second half of my cycle. It's as if my previous early pregnancy symptoms build up and then disappear about CD23. Could this be low progesterone? 

I had endometriosis and had laparoscopic surgery in March this year. The consultant said things should be OK now. I've had tests before, which show I don't have any other gynaecological problems. When I was younger, I had mild PCOS and bad skin.

I am really conscious of my body clock and need to know what I can ask my GP for in terms of tests. My GP is checking out thyroid at the moment.

I have a few other questions: 

  • Can I also ask for progesterone cream? Would I expect to feel ovulation still? It's the tearfulness and sore heavy boobs from CD17 that are horrible.
  • Should I be asking for a test, such as the killer cell, to check if my body is rejecting my hubby's sperm? I really do feel that something is building up each month but it can't be sustained for whatever reason.
  • Would you recommend I try the pill for a few months to regulate or kick start fertility? (One problem with this option is I had a minor DVT in 2000/1. It wasn't thought to be any genetic tendency.) Should I ask my GP to test for Hughes syndrome in case? 

A. Mr Bhattacharjee: First, if you are 39 years of age and have been trying to conceive for a few years, ideally you and your partner should have investigations. As you have mentioned, your consultant has treated your endometriosis recently and has reassured you, so I assume he/she has probably done the relevant investigations, including a dye test and laparoscopy, to check the fallopian tubes.

The fact that you have regular periods and have symptoms of premenstrual syndrome generally mean that you are probably ovulating fairly regularly. Nevertheless, with age, both the number and the quality of eggs decrease, as does fertility.

Generally, you are doing all the right things about trying to stay healthy, including decreasing caffeine and alcohol.

I am not sure what tests you have already had, but you can see your GP or a gynaecologist to have baseline tests including day 21-22 progesterone, HSG (if a dye test was not done), partner's semen analysis and a pelvic ultrasound scan.

A hormonal profile may be necessary, depending on your symptoms.

It's best to discusss your DVT and concerns about Hughes syndrome with your GP, since he/she will have access to your medical history. I would not suggest the pill for any of the reasons you mentioned. 

Q. Babyrose: My husband and I have been trying to conceive for 11 months now. I'm 32 and he is 34. We already have a three-year-old son. I have a regular menstrual cycle of 27-29 days. My DH and I are quite healthy, so I don't understand why it's not happening.

A. Mr Bhattacharjee: The fact that you have regular periods means you are probably ovulating regularly. Since you have been trying for only 11 months, I would suggest seeing your GP to get a referral to a gynaecologist. If you do not conceive over the next few months, start the baseline investigations.

It is important to bear in mind that conception depends on a lot of non-medical factors, such as timing and frequency of intercourse. 

Q.Boodle9: I've been trying to conceive unsuccessfully for over two years. I am currently on clomid, despite progesterone tests confirming that I ovulate on my own.

Prior to the clomid, I had quite short 24-day cycles with what I believed to be a short luteal phase of nine days. It has lengthened to a 14-day luteal phase on clomid. My consultant has said that a short luteal phase does not exist and that everyone's is more or less 14 days. Is this true? I don't understand how I can get a positive day 21 progesterone test, but then get my period two to three days later, unless my luteal phase is short? Can you shed any light?

Also, when I have PMS I have one to two days of allergies/hay fever-like symptoms that include lots of sneezing, itchy skin and runny nose. Is this normal? It's only since I started TTC that I noticed a pattern of these symptoms appearing two to three days before my period. 

A. Mr Priddy: I agree with your consultant that the luteal phase is 14 days. As you have a 24-day cycle, it is likely that you are ovulating on day 10 and your peak progesterone rise should be on day 17, although it still may be raised on day 21.

PMS is due to cyclical hormonal changes, which can alter over time. The symptoms you describe can occur but stress can also contribute to PMS. The worry of trying to conceive, without success, could be exacerbating your PMS symptoms.

I presume you've had the necessary tests including tubal patency, ultrasound scan, blood tests (hormone profile) and your partner's sperm was tested. If they are all normal, I would not use clomid for longer than three months. I would then consider a laparoscopy and a dye test to check for rare causes of infertility, such as endometriosis and peri-tubal/peri-ovarian adhesions.

"PMS is due to cyclical hormonal changes, which can alter over time, but stress can also contribute to PMS. The worry of trying to conceive, without success, could be exacerbating your PMS symptoms."

If the laparoscopy is abnormal, these conditions can be treated laparoscopically to improve your chances of conceiving.

If it is normal, I would advise trying for six months because the pregnancy rate would be higher over this time. If you're still not successful at that stage, I would recommend considering IVF. 

Q. FeatherFeather: I'm 34 and my partner is 39. We've been trying to conceive since September 2011 to no avail. In 2007, I had my right fallopian tube removed in emergency surgery - it had twisted on itself several times but it wasn't ectopic.

Last December, my husband and I had the necessary tests to figure out if there was a problem to explain why we weren't conceiving. All the tests came back fine (great sperm count, great egg reserves) except for the fact that I was diagnosed with PCOS.

I have very irregular periods ranging from eight day cycles to 54 days in the last year. I took clomid for five months starting this February. The first month I was on 50mg, then my dosage increased to 100mg. I ovulated twice in that time using a trigger shot. I had taken a break from clomid but just went back on it last week. I'm currently taking 150mg. My grist scan is on Friday to see if I've responded.

Is it worth giving IUI or injectibles a try before moving on to IVF? Is the one fallopian tube and/or PCOS a straight sentence to the IVF cave? I really would like to try all other options before doing IVF, as it just feels so invasive.

Also, is there any point in requesting I be put on metformin or femara? 

A. Mr Priddy: There appear to be two problems that are making it difficult for you to conceive:

  1. You have one fallopian tube.
  2. You have PCOS with irregular cycles and you are not consistently ovulating. Despite using clomid treatment for five months, it appears you only ovulated in two months.

I agree with you that IVF should be a last resort.

You have not mentioned the option of laparoscopic ovarian drilling/diathermy, which is the most appropriate treatment at this time. It would be beneficial because it would check whether your remaining left tube is open/patent. Furthermore, it would treat your PCOS and it has an 80% chance of making you ovulate consistently without clomid.

If you are ovulating regularly and your tube is open, you have a much better chance of conceiving naturally.

It is unusual to have a tube to twist spontaneously, as you had on the right. The laparoscopy will also carefully check the left tube and to see if it is normal or if you have a left para-fimbrial cyst, which could make it more likely for it to twist. If you have a cyst, it can be treated.

A hysteroscopy can be done at the same time to check the uterine cavity is healthy for embryo implantation.

I would not recommend IUI, as you only have one tube. Addditionally, FSH injections have potential side-effects, including ovarian hyper stimulation syndrome and multiple pregnancy, and they are expensive and require regular ultrasound scan monitoring. Instead, I would recommend laparoscopic ovarian drilling.

Patients who are ovulating but have only one tube can still conceive. I would recommend you try for six to 12 months after the laparoscopic ovarian drilling before considering IVF.

If you are ovulating on clomid alone, or in future with laparoscopic ovarian drilling, there is no need to also take metformin or femara but if the 150mg dose of clomid a is not working, you could use metformin in conjunction with it. The combination has been shown to be more helpful in causing ovulation.  

Q. MTPG: On 9 August 2013 I was six+two weeks pregnant. According to my gynaecologist, the pregnancy was healthy and the fetus had a strong heartbeat. On 4 September, dark brown spotting became bright red, so we went to the A&E. The blood test showed a failed pregnancy and low progesterone.

On 6 September, I started cramping and bleeding heavily, so we went back to the A&E and they confirmed the miscarriage. I was advised to wait for the bleeding to stop naturally.

On 20 September, the heavy bleeding started again. We returned to the A&E and I had an ERPC. I ovulated two weeks later. I'm currently taking 500mg of metformin twice a day for PCOS.

When should we try for a baby again? Would using natural progesterone cream help me to keep the baby? 

A. Miss Das: There is no ideal duration of time to wait before you can try to conceive again, however it is recommended that you wait until your normal period commences. This helps to date the duration of the new pregnancy more precisely and also ensures that any remaining problems from the miscarriage are fully resolved.

There is no strong evidence that supports using progesterone cream aids conceiving naturally. The ongoing international trial aims to answer this question.


Menstrual cycles and pre-menstrual syndrome (PMS)

Q. Fragpole: I am under 40, work full-time and have completed my family. I have recently been diagnosed with adenomyosis but do not really know anything about it.

I have severe back and pelvic pain at various points in my cycle and would like to know how to relieve the pain. Currently, the only thing that eases the discomfort is a hot water bottle on my lower back, which is fine at home but not at work. Any advice to help me cope day to day would be appreciated.

A. Mr MacDermott: Adenomyosis is a form of endometriosis in which the lining of the uterus is found growing within the outer muscle coat of the uterus. The lining responds to changing hormone levels and women typically have pain before and during their periods. They may also find intercourse painful. The diagnosis can be based either on symptoms, a pelvic examination or imaging, such as ultrasound or MRI.

"Adenomyosis is a form of endometriosis in which the lining of the uterus is found growing within the outer muscle coat of the uterus."

If symptoms are mild, then simple analgesia may be sufficient. Women with more severe symptoms could consider hormonal or surgical treatment. Progesterone is a hormone that can be given as a tablet or now commonly, through a mirena coil. This is a contraceptive coil that releases progesterone slowly to the womb over five years. When given continuously, progesterone causes the adenomyosis tissue to shrink.

GnRH analogues are drugs that work by inducing a temporary menopause. They can be very effective but are usually only given for six months because longer usage can cause osteoporosis. Advice should be sought from your GP on which is most appropriate for you.

Laparoscopy is a keyhole operation that can be used to look for endometriosis elsewhere within the pelvis. If it present, it can be treated thus reducing the pain. This may be the best option for women who are trying to conceive.

The adenomyosis tissue can only be removed surgically by performing a hysterectomy. This may be an option, as your family is complete. The risks of surgery would need to be considered on an individual basis but with keyhole hysterectomy now commonplace, it could be the right treatment for you. 

Q. ZippityDoodahday: My periods are very heavy and uncomfortable. I get severe mood swings leading up to them. I breastfeed, so don't want to use hormonal contraception. What can I do/take to make my flow lighter and improve my mood? 

A. Mr Farrell: The mirena coil would be the best option. It contains a very small amount of progesterone but it is suitable to use when breastfeeding. It is proven to reduce the heaviness and duration of periods. Some women say it improves other PMS symptoms. It is also a form of contraception.

"Simple changes to diet and lifestyle, such as reducing alcohol and caffeine intake and cutting down cigarettes, may all have a beneficial effect on the [PMS] mood swings."

Treating PMS without the use of hormones is difficult. Simple changes to diet and lifestyle, such as reducing alcohol and caffeine intake and cutting down cigarettes, may all have a beneficial effect on the mood swings.

Vitamin B6 (pyridoxine) has been shown to help with mood swings but it will not affect your menstrual flow. Tranexamic acid and non-steroid, anti-inflammatory drugs will help with menstrual flow, especially if your cycle is regular, however they are unlikely to have any impact on the mood swings. Therefore I would suggest you consider the mirena coil.

Q. Blamber: I stopped taking the pill in April after 15 years. I used ovulation sticks and took my temperature to find out when I was going to ovulate. I had my first ovulation in August and I got my period only a week later.

In the next cycle, ovulation was late again, with my period following a week later. After this, it took four weeks to ovulate and I'm now wondering when my period will be. I have been having problems with delayed ovulation and a short luteal phase. I'm worried there might be hormonal issues but my GP says it's normal after the pill. I cannot remember what my cycles were like before I started taking the pill.

How long does it normally take to get regular cycles back after going off the pill? Secondly, when is it time to start thinking there might be underlying problems?

A. Miss Shukla: After being on the pill for a long period of time it can take up to 12 months for your cycle to regulate.

If your problem does not settle after six months from stopping the pill, you can have a hormonal profile.

The presence of any other problems, eg heavy or irregular cycles or if you're planning on conceiving, will impact how quickly to conduct the test.

If you want to have a child soon, it is important to start a primary investigation. If not, you may want to wait a bit longer. It is worth discussing your situation with your GP.


Persistent thrush

Q. Spottybra: If we use any massage oils or lubricant prior to having sex, I end up with thrush. It started about 20 months ago. Since then, we have tried many different lubes. I have changed contraception to no avail. I don't use or do anything different to before I had the reaction.

I use a thrush cream containing nystatin from the GU clinic that relieves the symptoms but I just want my sex life back without thrush. How can I do this? 

A. Miss Downey: The first thing to do is to ensure your symptoms are the result of thrush (a yeast infection) by having swabs done.

There are two main types of thrush:

  1. The most common is easily cured with conventional treatment.
  2. The less common type needs prolonged treatment of between four to 12 weeks.

Your partner may also need to be treated, so I would advise you arrange a GP appointment together the next time you have an attack.

In some women, the oral contraceptive pill can increase chances of persistent thrush so discussing this with your GP would be helpful.

If the symptoms are not the result of thrush, then you may have an allergy to the condoms or the lubricants you use. In this case, use latex-free condoms. Read the contents of the lubricants carefully or avoid them all together. Your GP or local GU clinic are knowledgeable about causes and potential cures so they can suggest the best creams to use.

 

Gynaecological and sexual problems

Q. Buttermellow: I am 22 and I have had a long, long history of gynaecological problems.

  • Horribly sore and heavy periods that have seen me admitted to the hospital. 
  • Vulval/vaginal abnormalities: congenital severe hypertrophy, (this has been corrected to some extent through surgery), cysts, over production of skin oils, eczema, dermatitis.
  • Vaginal pain, dryness and tightness.
  • Breast tenderness and lumpiness.
  • Excess hair on my face, back, bottom and tummy.
  • I put on weight too easily.
  • Greasy hair.
  • Oily skin.
  • Complete intolerance of combined/mini pill and norethisterone.

I've ended up with vaginismus and sexual dysfunction-like issues - essentially, I can't have sex after years of issues.

I have been told that the problems are caused by hormones but all the ultrasound scans of my ovaries have come back fine. I have regular blood tests to check my hormones and they always come back entirely normal, so PCOS has been ruled out.

My GP thinks that I might have endometriosis or fibroids. I am having another scan to see if there's any changes in my uterus/ovaries. I did ask if an MRI/CT would help but GP said it wouldn't make much difference.

I am being sent for sex therapy to help with the sexual dysfunction and possibly getting dilator therapy.

I'm having the mirena coil fitted under epidural in three weeks, having a transvaginal scan and a pelvic exam at the same time.

I'm just getting fed up with everything being wrong. I have an examination approximately once a month, so I have had well over 60 examinations. I have completely disconnected from down below. I don't see it as mine, if that makes sense.

Apparently, the sex therapy and mirena coil will help, but I've somehow got to accept the fact that I will have regular examinations, to check my coil due to my vaginismus.

Could there be a condition that hasn't been diagnosed that is the cause of all the problems or is it possible to have many different conditions? I do get fantastic care from my local gynae team and GP – but I would be glad to have a second opinion. 

A. Miss Downey: I am sorry to hear about your complex gynaecological problems. As there are a few issues I will deal with each separately.

To have PCOS you need two out of three things:

  1. Excess testosterone (measured by a blood test with a protein called SHBG)
  2. Lack of periods
  3. Polycystic ovaries (which are identified by a scan)

It seems you can have the condition but normal-looking ovaries. I think you would benefit from having the tests mentioned above, as there are lots of treatments that can help. A specialist gynaecologist will be able to help you.

For excess spots, hair etc, there are two drugs that are useful: cyproterone acetate and metformin.

If you have not yet had a laparoscopy, then that would be very useful. It is a procedure that looks inside your tummy with a telescope and could identify the various causes of pelvic and period pain such as endometrioisis.

Finally, vaginismus can be treated with botox. It will help with the muscle spasm. If there is another cause of your painful intercourse a specialist in vulval disease may help.

Given your very complex problems, this advice is aimed at sending you in the right direction and I hope you get all the help you need.

Q. AHardDaysWrite: I had a second-degree tear after the birth of my first child. It was stitched and seemed to heal without problems. Afterwards I found intercourse impossible because it was so painful.

I was referred to a gynaecologist who said I had a lot of scar tissue and my vaginal entrance was narrower than normal as a result of the stitching. He performed a Fenton's procedure under general anaesthetic. It solved the problem and I was able to conceive again.

My husband and I could not have intercourse throughout my pregnancy as I found it too painful as a result of my swollen/engorged labia. (I had the same side-effect during my first pregnancy so it wasn't connected to the Fenton's procedure).

I chose to have an elective caesarean because my first birth was a shoulder dystocia and I didn't want to risk this again. I also wanted to avoid further perineal trauma. Therefore I wasn't expecting any problems with intercourse post-birth, but it's become very painful again.

Is there a possibility that the long period of no intercourse while I was pregnant has allowed some scar tissue to come back? Is it likely that I will need another Fenton's procedure?

A. Miss Das: No. New scar tissue does not form due to prolonged period of not having sexual intercourse. The pain could be due to generally low levels of estrogen soon after childbirth, which cause thinning and dryness of vaginal tissue. I suggest you consult your GP or gynaecologist.
 

Hormone levels

Q. Sharond101: I am 31 and have low oestrogen levels. Other than poor fertility, does this have any other affect on my health? 

A. Mr MacDermott: There are several causes of low oestrogens level at your age but the first thing to do is to clarify the accuracy of the diagnosis. Blood tests typically only measure the level of one hormone - oestradiol.

There are a number of other important oestrogens in the body. In order to confirm the diagnosis, I would expect your periods to be absent and the lining of your uterus to be thin on ultrasound.

Causes of a low oestrogen levels include:

  • Low body weight
  • Fluctuations in weight
  • Exercise
  • Early menopause
  • Benign tumour of the pituitary

It is important to see a doctor to try to get a diagnosis, as the treatments and outlook differ.

Regardless of the cause, the health consequences of low oestrogen levels are similar. Women can experience a range of symptoms that commonly occur at the menopause. These include:

  • Hot flushes
  • Mood changes
  • Dry skin
  • Low libido
  • Urinary incontinence
  • Vaginal dryness
  • Pain during sex

A more serious consequence is osteoporosis (thinning of the bones). It is very important for you to receive treatment if your low oestrogen levels persist for more than a year or two. At the age of 31, women are normally offered a choice between taking the standard contraceptive pill or hormone replacement therapy (HRT).  

Q. TEErickOrTEEreat: I'm 44 and have some perimenopausal symptoms, including hot flushes, night sweats and an irregular cycle, but my hormones level are all normal.

Is there something else that could be causing these symptoms? Is there anything that can be done other than HRT? I get migraines when additional hormones are added to my body. 

A. Miss Shukla: You can have perimenopausal symptoms long before the actual hormone levels go up. They can be there for as long as 10 years before your actual menopause. There are certain medications that can give similar symptoms, but it is very rare that they would be the result of another condition.

If you don't wish to use hormones, you could try medication meant to control hot flushes. Discuss this with your GP as he/she will ensure there are no contraindications that would prevent you from taking this type of medication.  

Q. Saltedcaramelplease: I suffer from acne, have excessive body hair and am an average build. My acne is always worse around the time of my period where I would get deep, painful spots on my chin.

I started suffering from migraines five years ago if I had too much chocolate/caffeine. I would get migraines with aura and feel incredibly nauseous.

In January 2013, my periods stopped. My gynaecologist did multiple tests every few months (hormone checks, blood tests and ultra sounds) but the results were always normal.

In December 2013, an X-ray revealed my uterine lining looked thin and my ovaries looking slightly fibrous, but definitely not polycystic.

My gynaecologoist was convinced my lack of menstruation was related to stress since there were no physical problems or symptoms. This was definitely not the case.

After a year of not menustrating, I was given a hormone pills to 'force' a period. During that time, I also got a migraine. I hadn't had a migraine in over a year because I was avoiding my trigger foods but I wondered if the migraines were affected by hormones. I knew birth control pills can help/worsen headaches.

"Although your hormone levels have been 'normal', there are limitations to laboratory tests. The true test of normality is whether your periods come regularly or not."

After I finished the pills, I did a test and ate some chocolate and started drinking coffee again. I never had a headache, let alone a migraine.

When I went back to see my gynaecologist, I mentioned this possible link. My gynaecologist said there was no connection and the only three things that cause lack of menstruation are stress, excessive exercise or a physical problem.

I continued enjoying coffee and caffeine and my periods came back. My skin also got worse - though I haven't had any painful spots yet. I don't think this is coincidence.

Am I correct in thinking that the two are related, or is it a weird coincidence? Are there any other foods that 'balance' hormones? I'm worried that my migraines will return. 

A. Mr MacDermott: The combination of acne and excess body hair suggests the presence of elevated levels of testosterone due to polycystic ovary syndrome (PCOS). This condition is more common in women who are overweight and usually results in infrequent or absent periods.

In your case, PCOS was excluded. The lining of your uterus was thin, which means that your oestrogen levels were low. This situation is commonly seen in women who are underweight, have lost a lot of weight or perform a lot of exercise. However, sometimes there is no clear explanation and this appears to be the case with you. It is a difficult condition to treat, so I am pleased that the situation has corrected itself.

Although your hormone levels have been 'normal', there are limitations to laboratory tests. The true test of normality is whether your periods come regularly or not. I am therefore not surprised that you have started to see some of your old cyclical symptoms.

I am afraid it is not possible to predict whether your migraines will recur, but the triggers for these can change over time so you may be lucky.


Menopause

Q. LoveAFullFridge: I started perimenopause at 41 and found the symptoms unbearable. Within two years, I was on HRT. I used the mirena coil plus evorel 50. Initially, they made a wonderful difference but after two to three years of use, my original symptoms returned. Plus, I became sensitive to the glue.

My GP switched me to sandrena 1.0, which reduced the symptoms but I experienced new side-effects and more mini-bleeds. A year later, the menopause symptoms began again. This time, my GP upped my dosage to sandrena 1.5. This helped for a while but then the symptoms came back.

Also, I have developed a painful tongue. It feels like I have burned my tongue - I haven't. The tip is red and I often have sore 'pimples' on it. I know that a scalded feeling in the mouth can be associated with menopause, but what about the other issues?

Why do my symptoms keeping returning and what can I do about it? Is there an HRT regime that will properly help me? I cannot cope with the menopause symptoms.

A. Miss Shukla: You can try using HRT with 2mg of estrogen. If you don't want to use hormones, you can use non-hormonal preparations, such as selective serotonin uptake inhibitors.

For your tongue problems, you should see your doctor to establish the cause.
 

 

Last updated: 04-Nov-2013 at 12:22 PM