• Dr Peter Chew

Fertility is not a tap

For the past 18 years, Mrs M, a 30 year-old teacher has been suffering from menstrual cramps.

“ I had my first period at 12. The pain wasn’t too bad, and it was relieved after a hot shower. But by my late teens, it was getting more severe and I had to take Panadol regularly,” she recalled.

“Later, Panadol was not effective anymore and I have to take other stronger pain killers. My mum took me to her gynaecologist, who prescribed oral pills to me and told me that it would disappear after I had given birth.

I took the pills and the pain was relieved somewhat though not completely.”

“ I got married at the age of 26. My husband is 5 years my senior. Procreation was never in my priority list as I assumed that fertility can be turned on and off like a tap, and that we can have children when we want it to happen. It took me 3 years to decide it’s time for me to start a family. I have been trying for the past year with no result. This is the reason of my visit here”

“What about your menstrual cramps” I interrupted

“Menstrual pain returned as soon as I stopped the pills and I noticed discomfort at the back whenever my husband was too harsh during deep penetration.” “Any investigation done?” I asked.

“Yes. An ultrasound scan. I was shock to know that I had an ovarian cyst in my right ovary.” The gynae then suggested an operation where a telescope was inserted through my belly button to check my womb (laparoscopy). I reluctantly agreed as the pain was getting unbearable.”

“What were the findings?” I asked.

“My gynae found small chocolate-coloured spots of menstrual blood at the back of the uterus and ovaries which she removed during the operation. My pain went away and I was symptom-free for the next few years until recently when I experienced pain during sexual intercourse. The backache and menstrual pain returned and I had pain when I passed motion during menses.”

When I examined AG, her uterus was tender to the touch and relatively immobile. An ultrasound scan showed an ovarian cyst about the size of a tennis ball on her left side. It was subsequently removed through key-hole surgery and was confirmed to be an endometriotic cyst or “blood cyst”.

Endometriosis is a common and troublesome disease affecting about one in 10 women of reproductive age. In women with fertility problems, the number may be as high as 50 per cent.

It is also a progressive disease, as is the case for AG. The lining of the womb (endometrial tissues) is spilled into other parts of the reproductive organs including the fallopian tubes, ovaries and the back of the womb.

These abnormal and wayward tissues bleed every month during menstruation. The surrounding areas become inflamed and form scars which pull on the nerve endings and cause pain. But some women will have little or no pain despite having extensive disease while others may have severe pain with only a few small affected areas.

The endometrial tissues trapped in the ovary will bleed and lead to the formation of the dark, thick and chocolate- coloured cyst known as “chocolate cyst” or “blood cyst”.

It may leak and form adhesions (abnormal tissues that bind organs together). The adhesions can block the fallopian tube and interfere with ovulation, causing infertility.

The exact cause of endometriosis is not well understood. A familiar association exists as it can affect many siblings in a family. Past pelvic infection can also be a cause.

Common symptoms of endometriosis include menstrual cramps, backache and pain during sexual intercourse. Menstruation may be irregular, with staining before or after menstruations. There may also be clots in the menses.

An ultrasound scan may be misleading in the diagnosis of endometriosis. It is usually normal if there is no cyst formation as in the case of AG when she consulted the first gynaecologist. The diagnosis is based on clinical suspicion and confirmed by laparoscopy.

A blood tumour marker test (CA125) is also not very helpful as the level may be normal or raised. When a cyst is present, surgical removal and microscopic examination is the only way to confirm the diagnosis as in AG’s case.

The recurrence of endometriosis is very common. It will only dry up after menopause when the lesion is no more stimulated by ovarian hormones.

Pregnancy has a beneficial effect on endometriosis. Hormonal changes cause the diseased areas to become inactive. As infertility may be a consequence of endometriosis, I discussed with AG and her husband the possibility of their conceiving a baby. They heeded my advice and AG is now pregnant.

Give ample time and allow for unexpected delays, and do not wait till it’s too late. Watch that clock!

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