I have spent the last 35 years listening to women speaking of the compromises they make for what they think is a normal part of life. By the time they see me they may have questions in their mind as to what is normal.
If you ask a general question like
“How is your bladder?”
“How is sex?” or
“How are your bowels?” and get an answer like “Oh,OK”, “pretty good”, “I can’t complain” or
“I have a weak bladder like most women my age”, it is a clue to explore if you have the time.
Let us explore this territory.
Painful, heavy or prolonged periods are common but never “normal”, including and especially in teenagers. No one should have to miss school, work or social engagements because of their periods. Treatment should always be offered. A combination of a combined contraceptive pill and a NSAI usually works. If not, the diagnosis is virtually always endometriosis or adenomyosis. A laparoscopy at any age may then be indicated. Not treating endometriosis early can have very severe adverse outcomes including infertility and chronic severe pain.
Periods can be reduced or stopped with a Mirena but this may not be suitable for a young woman and may not control endometriosis. Continuous high dose Provera can completely supress periods and endometriosis and can be taken for years if tolerated. 90% of women do tolerate it. Authority prescriptions make it cheaper. The generic Ralovera does not work as it appears to be much less bioactive.
Most bladder problems can be diagnosed with a few questions.
For an overactive bladder:
How frequently do you have to pass urine?
Do you have to go urgently and do you always make it. (“usually” means “NO”)
How many times do you get up at night?
Treatments include physiotherapist supervised exercises, tablets or skin patches.
For stress incontinence:
Do you lose urine when you cough or sneeze or run?
If incontinence occurs: Does it worry you much?
These problems can be made better or fixed.
In general, physiotherapy can help if the patient is willing to continue with it. Drugs help overactivity but rarely help stress incontinence. Operations help stress incontinence and may improve bladder overactivity. MonaLisa laser treatment can help both but not reliably.
In many women, these problems are mild and they can decide how for to go with treatment with the option for no treatment.
Are there symptoms such as new anxiety or depression, hot flushes, can’t think, no energy, dry vagina, vulval burning when voiding or painful intercourse? Some women are frightened that they are developing dementia.
In a woman over 40, these can all be symptoms of menopause but may be thought to be normal “at this age”. HRT may give dramatic improvement.
Undiagnosed menopausal symptoms can lead relationship problems, destruction of a career, depression, physical discomfort and usually can be treated. If you are unsure if symptoms are due to menopause, a trial of HRT should give the answer. Oral or patch HRT using the usual oestradiol helps everything except vaginal and vulval problems. The latter need oestriol as found in Ovestin cream.
Vaginal oestradiol as in Vagifem does not seem to help.
Progestagen therapy is also needed if a uterus is present to reduce the risk of endometrial cancer.
The aim of treatment is to improve quality of life.
Oestradiol (the main HRT) should not be used after recent breast cancer but local vaginal oestriol cream does not seem to increase the risk of cancer recurrence. The MonaLisa laser is usually very effective in improving vaginal and vulval symptoms.
The Australian Menopause Society has updated its advice over the years to now recommend that all menopausal women should be offered HRT due to its positive benefit to bones and blood vessels.
Prof Rod Baber who is considered an HRT Guru in Australia recommends HRT in the form of Oestradiol patches and oral micronized progesterone. This, he says, does not increase the risk of DVTs or breast cancer.
In a premenopausal patient, the two main causes are vaginal scars which the patient can usually identify and vaginismus in which they have no idea why it now hurts.
Vaginal examination will diagnose which cause may be present and both may be found together. It may also suggest Lichen sclerosis which should always be confirmed and treated if present. The pain from scars and Lichen sclerosis can be fixed.
In the absence of another cause, a vaginal retraining program using dilators will cure vaginismus in 90%.