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Heavy menstruation:
Heavy menstruation is actually a vague term as which is perceived as “heavy” by some may be felt ‘right amount’ by some. Definition tells more than 80 ml of blood loss should be considered heavy. However, changing of pad frequency and anemia is important marker of heavy menstruation. Causes include fibroid , adenomyosis, endometrial polyp, endometrial hyperplasia etc. If an adolescent girl experience heavy period, bleeding disorders and congenital problems to be excluded first. Other medical problems like thyroid gland disorder, liver disease, hypertension, kidney disease and different medications may also cause heavy menstruation. If no reason of heavy menstruation is found it is termed as dysfunctional uterine bleeding (DUB).
Treatment depends on age, suspected pathology, patient’s wish, and family completed or not. However, all the patients should be given a trial of oral medications before surgical options like IUS insertion and endometrial ablation. Hysterectomy ( surgical removal of uterus) should only be considered as ultimate treatment with 100% efficacy.


Very little /no menstruation :
If no menstruation, pregnancy need to be excluded first in any women at reproductive age group. There are various other causes of no/little menstruation. If an adolescent girl of 14 years does not start to have any menstrual bleeding, she should be seen by a consultant gynecologist on emergency basis. Most of them are due to imbalance of different hormones in the body and in most of the patient, treatment with oral medicine should solve the problem. Some common example include PCOS, hyper-prolactinemia, hypothyroidism etc. Vaginal /uterine structural problems (e.g. Uterine synechie formation , imperforate hymen) are some of the structural problem which can cause amenorrhea and will need gynecological surgery to reverse it. Appropriate diagnosis is the key and should be individualized. Experience and empathy of the gynecologist is the key factor.


Pain during menstrual cycle :
Some lower abdominal crampy pain during menstruation is very common gynecological problem especially in adolescent girls and young adults. Generally this pain persists for first two days of menstruation and then decline. Often this pain goes down after first pregnancy. Management mainly by reassurance and simple analgesics or antispasmodics. However, if the pain is too severe to affect daily life, if the pain does not subside by the 2nd day, if the pain is gradually worsening with age then a specialist gynecologist should be consulted to exclude any serious gynecological pathology like endometriosis, fibroid, adenomyosis, ovarian cyst, endometrial polyp, pelvic inflammatory disease. Many of the congenital anomaly of the female genital tract also causes severe menstrual pain. A meticulous history taking and Investigations like ultrasonography should exclude any serious cause of dysmenorrhoea.


Pain lower abdomen :
This can be due to various reasons including non-gynecological causes. However, if related with menstruation, it is likely to be of gynecological origin.
Most important gynecological cause is endometriosis. Other causes include fibroid, adenomyosis, ovarian cyst, endometrial polyp, pelvic inflammatory disease. Adhesion & Urinary tract infection can also present with pain lower abdomen.
Appropriate diagnosis of the cause of the pain is very important and all the gynecologist should be very careful before any surgical intervention. A patient with pelvic pain with a small subserous fibroid in USG may not be originated from the fibroid at all but could be due to other unrelated cause like adhesion due to previous caesarean section.


Vaginal/vulval irritation
This is a very common symptom (commoner in post menopausal women) and most of the time associated with some other problem or infections. However, in few women, cause can not be clearly found and these are the patients who pose real challenge for a Gynecologist. Mostly treatment is with medicine but biopsy may be taken if neoplasia or vaginal or vulval intraepithelial neoplasia is suspected.


Menopause & perimenopause
Menopause is the period of women’s life when ovaries stop to produce oestrogen & progesterone.The period when oestrogen in the female body is low but not as low as in menopause is called perimenopause. Just like puberty it is a time of change in a women’s life. Unfortunately, most women perceive menopause as a very negative thing in their life. But menopause does not mean stoppage of relationship or sexual activity. Moreover, this period is free of fear of pregnancy & hassale of contraception.
There are mainly three types of problems women report to a gynecologist during this phase.


Vaginal White discharge
This is very common gynecological complain of the reproductive age group women. Some amount of discharge is normal and needed to keep the area moist. Vaginal and cervical pathologies are generally associated with this common gynecological symptom. A PAP smear should be mandatory with this symptom. Local antibiotics & anti fungals are also commonly used as vulvo-vaginal or cervical infection by different pathogens are the commonest cause. Long standing white discharge is difficult to treat as long term benefit with treatment is not achieved. Chronic cervicitis is mostly blamed but no particular treatment is fully useful. Procedures like colposcopy, chemical or electrical cautery of cervical os, cervical biopsy, LLETZ are all in use by the different gynecologists. Sometimes, the symptom of white discharge may not be associated with specific pathology and individualized long term treatment may be needed.


Leaking urine (urinary incontinence)
Leaking urine is actually more common than commonly thought and more common in females than male. Leaking urine may not be associated with gynecological abnormal condition. It’s considered as Urogynecological condition and should be treated by an good urogynecologist. Most of the post menopausal women and some younger ladies have some problem with holding urine. Infection and bladder tumours to be excluded first.
There are basically two types of urinary leak but mixture of these two types of incontinence are found commonly. Pelvic floor exercise is very useful for both types and all the patients should be encouraged to do this.
First- when patient have problem in holding as she feel like going to toilet. This is called overactive bladder problem. Most of the problem can be corrected by medications.
Second – when small urine leak happens with cough, sneez or weight lifting etc. this is mainly due to some angulation problem in the bladder outlet and called Stress Urinary incontinence. Most of this problem will need surgical correction. ( TVT /TOT operation)


Painful intercourse
Painful intercourse is a problem with physical and psychological sequel for most of the patients who suffer from it. Proper and sympathetic interview of the patient should give the clue of the cause of this to an experienced gynecologist. Examination is only needed uncommonly. Serious organic causes include endometriosis, infections, cervical & endometrial polyps and ovarian cysts. Vaginismus and psychological trauma are also very important cause of this symptom. Sympathetic counseling with proper diagnosis & treatment by an experienced gynecologist can solve this problem.

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