Category — Blog

(C) Lauri Romanzi 2010

Pelvic floor disorders include problems with urinary incontinence, pelvic organ prolapse, fecal incontinence, fistula, urinary tract infections, and mechanical sexual dysfunction. Who wants to think about this stuff?  Well, for starters, women who suffer these disastrous conditions.

Pelvic organ prolapse, on which I’ve written aplenty, can sometimes induce a rather nasty condition called overactive bladder. Overactive bladder happens when your bladder muscle (yes, the bladder is a muscle, an automatic muscle, like the muscles in your intestines or your heart) decides to EVACUATE, any time it wants to, whether you’re on the toilet or riding the bus. Women with overactive bladder often report a compelling, sometimes sudden urge to void (urinate) that is difficult or impossible to defer. She may find her bladder waking her from deep sleep many times at night with this same horrible urgency. When this urgency control is “difficult”, she’s Kegeling her legs off, squeezing her thighs together and sweating bullets trying to make that horrible urge feeling stop so she can uncross her legs and dash to the nearest powder room. When the urge to void is “impossible” to defer, she wets her pants. It’s messy, horrifying, and terribly unsexy.

Urge Incontinence from Overactive Bladder

While most cases of overactive  bladder are idiopathic (medicalese for “no apparent cause”), some cases are caused by prolapse.  When the bladder or uterus (or both) prolapse, the urethra can be kinked or compressed, obstructing urine outflow and making it difficult for the bladder to empty completely. Obstructed bladders are cranky bladders, often becoming overactive in response to this interference with emptying.

A recent multicenter European study published in Neurourology and Urodynamics showed a distinct correlation between severe pelvic organ prolapse, bladder outlet obstuction, and overactive bladder. Prolapse can obstruct bladder outflow and if it does, the bladder tends to become overactive, reminiscent of that vaudeville song, “The head bone’s connected to the … neck bone…”.  In this timely review, they also found that successful prolapse surgery often, but not always, calmed down bladder overactivity by un-blocking the urethra and normalizing bladder outflow. The connection between prolapse, bladder outlet obstruction and overactive bladder

Women with prolapse and bladder problems often want to know if surgery will fix both. This study helps us understand that it indeed may help fix both the prolapse and the obstructed/overactive bladder disorders in a large portion of women with this unhappy combination. For years, I’ve used pessaries (vaginal widgets that comfortably hold prolapse in place) to help predict whether or not prolapse surgery might also stop obstructed voiding and overactive bladder, and most of the time it correlates well to surgical outcome. And sometimes, the patient is so pleased with the pessary that she cancels the operation.

For a detailed case report on women with prolapse, obstructed voiding and overactive bladder, click on this MedScape review:

Dr R for MedScape- prolapse, overactive bladder, stress incontinence, obstructed bladder

http://cme.medscape.com/viewarticle/700135

One last note for women with prolapse and bladder problems – there is another urinary incontinence condition, called stress incontinence, that may actually increase with pessary use or prolapse surgery, because a stress – incontinent urethra may actually seal better with the kinking and compression caused by prolapse, and may therefore increase when the prolapse and kinking are mechanically corrected. Stress incontinence is caused by poor urethral closure that allows urine to leak out with strenuous physical exertion, like sneezing or coughing or opening a window or lifting heavy grocery bags. No urgency, just “exert and squirt”.

Stress Urinary Incontinence = "Exert and Squirt"

If you have prolapse and stress incontinence, your problems require therapies for prolapse and therapies for stress incontinence. Prolapse therapy options usually involve pessary use or reconstructive surgery. Stress incontinence options include Kegel exercises with pelvic floor physical therapy, medications, or procedures such as urethral bulking injections or minimally invasive sling operations. You can do prolapse reconstruction and urethral sling in one operation, for instance, taking care of both your plumbing and your renovation problems at the same time (on Plumbing and Renovations).

Prolapse or no prolapse, urge incontinence from overactive bladder and stress incontinence from a weak urethral seal can plague any woman at any age. About 13% of women with overactive bladder are under the age of 35, and up to 30% college female athletes report regular urinary incontinence of one sort or another during training and competition. It comes with the territory, and it increases in prevalence as women age.

1/3 of incontinent women suffer only stress incontinence, 1/3 only urge (overactive bladder) incontinence and 1/3 suffer a mixture of both overactive bladder / urge incontinence AND stress incontinence.

If you have incontinence, or prolapse and bladder problems, make sure you don’t undertake any therapeutic measures without first understanding if you have overactive bladder, bladder outlet obstruction, and/or stress urinary incontinence. It is absolutely possible, and not at all uncommon, to have all three conditions if you suffer severe prolapse. Take the time to sort it all out, make sure it’s clear in your mind, then work with your doctor to set a common-sense course of action to restore your core to normal anatomic and physiologic function.

(C) Lauri Romanzi, 2010

Pelvic organ prolapse, the medical term for vaginal bulges caused by damage to the connective tissues supporting the organs above and around the vagina (the uterus, bladder, rectum and vaginal opening), is a silent epidemic affecting women worldwide. Common terms include dropped bladder, dropped uterus, rectocele and vaginal laxity. Recent estimates using US Census population projections anticipate a 46 percent increase in pelvic organ prolapse among American women over the next 40 years, from 3.3 million in 2010 to 4.9 million. According to a recent study from Duke University, it is possible that the number of women with prolapse will be even greater than this, up to 9.2 million. Prolapse may occur to varying degrees in up to 50 percent of women who’ve given birth. Prolapse can even cause depression.

Childbirth contributes to most prolapse conditions, however genetics, medical disorders such as connective tissue disease, diabetes and obesity, and lifestyle habits have all been shown to contribute to pelvic organ prolapse risk. I’ve had many young women in their 30’s with prolapse who’ve never been pregnant, or found themselves suffering a dropped bladder after an easy and quick delivery of their first normal (or even low) weight baby. Even cesarean section is no guarantee against pelvic organ prolapse, with 5% of women in one recent study suffering severe, palpable and visible prolapse even though they delivered by cesarean section before going into labor. The role of Kegel fitness and Kegel exercise in the prevention of treatment of pelvic organ prolapse is just recently getting the research attention it deserves, and Kegel exercise may well play a role in prevention and treatment of prolapse. But for certain, if you suffer prolapse that looks like the image below, no amount of pelvic floor Kegel exercise, or any other kind of exercise, will pull your parts back into place.

Prolapse surgery often comes with a recommendation for hysterectomy, but the latest trends highlight new techniques that fix the prolapse just as well without removing the uterus. When the uterus prolapses it can be resuspended by one of several techniques, and the surgery holds up just as well as when a hysterectomy is included in prolapse repair surgery. This uterine resuspension concept is an exciting new option that allows many women to undergo prolapse repair surgery without removing any organs.

While many women with prolapse believe just one single body part is out of postion, most commonly, prolapse involves hernia-type displacement of several organs. When the bladder drops, formally called a cystocele (siss-toe-seal), it is often accompanied by a rectal bulge, called a rectocele (wreck-toe-seal).  Laxity at the vaginal opening, called a perineocele (pear-in-ee-oh-seal) results when the perineum loses connective tissue bulk as a result of childbirth.  Uterine prolapse is called, well, uterine prolapse. But behind a prolapsed uterus, it is common to find an internal small intestine hernia called an enterocele (en-tare-oh-seal).

When you put all these prolapse possibilities together at their absolute worst, it looks like this:

Courtesy WomensVoicesForChange.org

My role as guest blogger gives me the opportunity to demystify this deeply troubling malady.  For more information, check out this first of 2 posts on pelvic organ prolapse done for my friends at Sweet Talk on The Spot:

Dr R covers Prolapse, Part 1 for Sweet Talk on The Spot

To review Dr R’s book on prolapse, see www.plumbingandrenovations.com

If you have any questions, send in your comments on this post or post your own question to Ask Dr R.

(C) Lauri Romanzi, 2010

I urge you all to check out the entire content on Women\’s Voices for Change, an online resource for grown women and the people who love them.

Betty, a woman with uterine prolapse, recently wrote in to this blog, asking advice after her doctor told her she would need a hysterectomy to fix her prolapse. We now understand that the mechanics of prolapse are all about those ligaments, and that the uterus, literally, contributes nothing to prolapse other than it’s change in position from “up there” to “out there”.  Dr. Pat Allen, Gynecologist extraordinaire and founder of Women’s Voices for Change, called me in to pinch hit on this one, and with bases full, Dr. R goes to bat:

Dear Betty,

You’ve done a great job of describing a condition that many women are intimately familiar with and, like you, embarrassed to talk about. I asked WVFC Medical Advisory Board member Lauri Romanzi, M.D., a specialist in reconstructive pelvic surgery and urogynecology, to respond. Which she did, pulling out a drawerful of medical illustrations to help explain what’s going on in your body, and why a hysterectomy isn’t the answer. —Dr. Pat

Betty\’s Prolapse Problem

(c) Lauri Romanzi 2010

Vaginal rejuvention, a mystical term with many facets, new darling of cosmetic surgery and battle cry of the “anti-medicalization of female sexuality” crusade, is a marketing term with no formal medical definition, this despite the American College of Obstetrics and Gynecology 2007 Clinical Practices Bulletin on the topic that was rife with both admonishments against some, and guarded approval of other, procedures advertised under this “VR” label. Some 3 years after the ACOG bulletin, concern and confusion reign on as the definition of vaginal rejuvenation continues to mutate.  

As a reconstructive pelvic surgeon and urogynecologist, I’ve been dealing with “Vaginal Rejuvenation” requests of all types since the term went public. As far as I can tell, the public’s interpretation of vaginal rejuvenation falls into three groups, listed here in order of increasing controversy and decreasing volume of safety & efficacy data:

Procedures to correct prolapse and incontinence

Procedures to alter the appearance of vulvar structures

Procedures alleged to enhance female sexual gratification

For a perspective-setting preview, consider reading this 2009 review of vaginal rejuvenation by Dr. R, and an excellent piece on birth plans written by Sharon Bond, PhD, Certified Nurse Midwife, here:

NAFC Quarterly Update Vaginal Rejuvenation & Childbirth Planning

These 2 articles, written for the National Association for Continence quarterly newsletter, dovetail nicely. As it turns out, much of what patients consider “vaginal rejuvenation” has a lot to do with childbirth-related changes in pelvic floor anatomy and function. As a contributor and member of NAFC (National Association For Continence, www.nafc.org), I share this fantastic online resource for information on pelvic floor disorders.  While the NAFC focus is on bladder and bowel control (as evidenced in the name), they do a great job of bringing up-to-date information on sex and well being to the public.

THE INSIDE SCOOP ON VAGINAL REJUVENATION

UPDATE 2010

Vaginal rejuvenation is a tenaciously fashionable concept, still with no strict medical definition. Yes that’s right, things vaginal continue to be fashionable. And, as with fashion, much is left to creative interpretation.

For many women, the childbearing, peri- and post- menopausal years come with pelvic, sexual, urinary, rectal or vaginal problems. Vaginal laxity, pelvic prolapse, poor bladder control, vaginal dryness, sexual pain, or waning sexual response can truly affect how you feel about yourself and your ability to enjoy your life. In medicine, we use “quality of life” questionnaires to measure the affect of such symptoms on health‐ mental health, ability to work, play, travel, enjoy sex, and feel normal and intact as a woman. If things aren’t right, you have options. These options, under the newly minted term “vaginal rejuvenation”, continue to spark controversy, raising concerns about safety, efficacy, and medical ethics.

With those options come obligations. Your obligation includes examining your motivations, taking stock of the overall impact of the condition(s) on your quality of life, and obtaining several medical or surgical opinions before you start any therapy or sign up for any surgery.  The doctor’s obligations include sorting out whether your condition(s) warrant physical, medical or surgical therapies or some combination thereof, and to help you understand what the risks, benefits and alternatives are for your personal mix of issues and symptoms.

Vaginal rejuvenation skipped onto the medical stage a few years ago, with no formal medical definition, in response to increased demand for  cosmetic alteration of gynecologic structures, most commonly the labia minora (inner vaginal lips). It has since come to mean any variety of procedures and treatments, many with an established record of use for generations, and others with no established history, little to no safety or efficacy data, and no predictable result.

“Vaginal Rejuvenation” for pelvic organ prolapse, vaginal laxity, and incontinence

Women with vaginal laxity, prolapse or  incontinence  might not know what “prolapse” or “incontinence” truly mean, but all women instinctively understand the notion of vaginal rejuvenation.

For a new mother, vaginal rejuvenation may mean improving pelvic muscle tone, and vaginal snugness with Kegel muscle exercises in a formal postpartum rehabilitation program of biofeedback (think “vaginal video games”) and pelvic floor electrical stimulation. For a 43 year old tennis‐playing mother of 3, it could mean minimally invasive surgery for “exert and squirt” type urinary incontinence (stress incontinence), with “perineoplasty” to restore the perineum (connective tissue between vagina and anus) back to normal, “rejuvenating” bladder control and vaginal snugness to pre‐baby condition. Or uterine resuspension, bladder lift, rectum reinforcement (rectocele repair), perineoplasty and a minimally invasive sling for combined prolapse and stress incontinence – what I call “the blue plate special.”

Vaginal Rejuvenation Traditional Medical Terminology

Vaginal muscle fitness = Pelvic Floor Rehabilitation a.k.a. Kegel Exercise

Lift a dropped bladder = Anterior Colporrhaphy*

Tighten a vagina permanently widened by childbirth= Perineoplasty

**Fix a bulging rectum = Posterior Colporrhaphy

Repair a leaky bladder = Urethral Sling or Urethral Bulking Injections

Restore anal control = Anal Sphincteroplasty

Lift a dropped uterus = Uterine Resuspension, aka Hysteropexy

***”Vaginoplasty” = creation of a vagina (often using  loop of intestine) in a woman born with congenital absence of the vagina, or creation of a vagina in a woman whose vagina is scarred shut from disease (fistula, radiation effect, infection, radical pelvic cancer surgery). More recently, under the marketing concept of vaginal rejuvenation, it has come to mean any combination of procedures from any of the basic three categories (prolapse/incontinence, cosmetic, sexual enhancement) for women without congenital or acquired obliteration defects of the vagina.

*Also referred to as “anterior repair”

** Also referred to as “posterior repair”

***On “vaginoplasty”, in the realm of “vaginal rejuvention” for women born with normal vaginal anatomy, this procedure, commonly attached to the word laser, as in “Laser Vaginoplasty” or “Laser Vaginal Rejuvenation”, carries no description in any medical or surgical textbook or peer review journal.  As of June, 2010, neither “laser vaginoplasty” nor “laser vaginal rejuvenation” are now or ever have been taught in any surgical or gynecological residency training program, nor in any urogynecology, female urology, plastic surgery, or other reconstructive surgical subspecialty fellowship training program. If you want to know about laser vaginoplasty, patient choice is restricted to consultation with a doctor who paid to be trained by the founder of the laser vaginal rejuvenation procedure. These doctors pay a fee to spend several days learning the procedure(s). The fee includes the franchise purchase, after which purchasing physician participates in an exclusive, robust webmarketing network restricted to purchasers of the franchise, the only doctors who may perform the laser vaginal rejuvenation procedures. These franchise-purchasing physicians are under contractual obligation that forbids discussing or otherwise disclosing the actual technique to anyone who has not purchased the franchise, including colleagues or the press. As such, and despite patient satisfaction testimonials on the franchise physician websites, there is no scientific, peer reviewed data in any peer reviewed medical journal documenting the actual technique, efficacy or safety of laser-based vaginal rejuvenation procedures

For some women, “rejuvenate” = “relubricate” (see When rejuvenate = relubricate). Vaginal dryness, poor lubrication and reduced clitoral sensitivity, common symptoms after menopause, are easily remedied with low‐dose vaginal estrogen therapy, treating the target areas without giving your body a full dose of estrogen.

With “vaginal rejuvenation” in the public lexicon, many women with prolapse or menopause-related vaginal dryness or problematic urinary incontinence eagerly seek out a little rejuvenating, often the same women who reject the unsexy but medically accurate labels of “pelvic organ prolapse” , “vaginal atrophy” or “incontinence.” For women over 50, the risk of severe pelvic organ prolapse or urinary incontinence are about 5%, and this increases in women who are overweight, or who have birthed children, particularly large babies and long pushing stage of labor.  A recent study of over 3000 women ages 50‐61 showed 6% with symptomatic, high‐grade prolapse.  Some estimates show 50% of women who’ve born children will have variable degrees of pelvic organ prolapse, from asymptomatic to gravely symptomatic.  By 2050, the number of women with urinary incontinence is expected to increase by 46%, and those with pelvic organ prolapse by 55%, with the number of American women with at least one pelvic floor disorder increasing from 28.1 million in 2010 to 43.8 million in 2050.

Whether you call it prolapse repair, incontinence therapy, or vaginal rejuvenation, pelvic floor disorders condition and related treatments (with “laser vaginal rejuvenation” the exception) come with generations of experience documented in medical and surgical texts and reams of data in myriad peer-reviewed medical journals.

“Vaginal Rejuvenation” to alter the appearance of the vulva and vaginal opening

Reduce and remodel inner labia = labiaplasty

Restore the hymen to a virginal state = hymenoplasty or “revirgination”

Reduce wrinking of outer labia = labial filler injections (of fat, collagen or other filler)

Labiaplasty reduces and remodels large inner labia (labial hypertrophy), or restores symmetry to unbalanced labia (labial asymmetry). Women requesting labiaplasty reduction and recontouring of the inner labia minora is often  report physical discomfort from labial catching, chafing, rubbing and folding in clothing or with sexual or other vigorous activities like tennis, yoga, running and biking. Women’s current propensity to depilitate all vulvar hair and wear thongs, the ad infinitum wearing of jeans formerly reserved for the under-30 set, intertwine with inevitable yet subtle changes in inner-outer labial consistency and relative size and natural age related vulvar wrinkling, resulting in unprecedented complaints of physical discomfort from this artificially increased labial exposure. I find many such patients adamantly unwilling to restore Mother Nature’s natural labial cushion that comes from full-growth pubic hair, full crotch underwear, and pants that aren’t painted on. I tell every labiaplasty patient every time, and 9 times out of 10, this (self-selected and therefore biased) group opts for the labiaplasty operation over nature’s blueprint.

The role of enculturation cannot be underestimated. On the other end of the labial alteration spectrum, from a region of the world more famous for rite-of-passage female genital mutilation than female sexual gratification, comes the regionally popular central African practice of labial elongation, believed to enhance female orgasm, female ejaculation, and sexual satisfaction for both male and female sides of the coital equation: Rwandan women enhance gratification with \”labial elongation\”

Hymen restoration involves careful reconnection of the hymen remnants to recreate a pseudo-virginal state, most commonly requested by women from cultures requiring virginity at the altar, but gaining popularity here in the States from women seeking “revirgination”. This procedure meets with much scrutiny, given the inherent cross-cultural and socio-ethical issues involved.

Labial bulking of the outer labia reduces age-related wrinkling as the body’s youthful fat pads diminish not only in the vulva, but also in the cheeks, hips, extremities and around the joints. These fat pads are well understood by cosmetic surgeons, who commonly plump up  facial cheeks made hollow by age-related loss of facial fat, often using liposuctioned fat from the patient’s own buttocks, abdomen or thighs. Popularized by these same cosmetic surgeons, women with age-related fat pad volume loss in the labia majora reportedly undergo similar bulking filler injections into the labia majora in cosmetic surgery offices.

As with rhinoplasties, lip enhancements, cheek and buttock implants, liposuction and all other cosmetic procedures, these “not medically necessary” labial alteration procedures are not covered by insurance. The physician is obligated to evaluate patient motivations, and to do their professional best to avoid performing them on women addicted to cosmetic procedures or suffering from body dysmorphia, both contraindications to cosmetic procedures.

A woman seeking labiaplasty for severe congenital asymmetry or labia that routinely catch, tear or chafe with sporting or sexual activities are not the same as patients responding to cruel comments from an unworthy sexual partner or insecure because they “don’t look like the women in porn movies”. Labiaplasty procedures are included in surgical texts, with techniques and data published in peer reviewed medical and surgical journals. Much controversy surrounds labial and hymenal procedures, taken as yet another sign of the increased medicalization of female sexuality, with “female sexuality as a newly minted profit center for unethical surgeons and greedy pharmaceutical corporations” as the banner-head under which such protests march. (see Professor Leonore Tiefer)

The controversy rages on, hitting fever pitch with the next category of rejuvenation procedures:

“Vaginal Rejuvenation” to enhance sexual gratification

Clitoral unhooding

G-Spot amplification (a.k.a. the G-shot)

Sub-clitoral bulking injections

This category of VR procedures carry significant risks, with sparse to no efficacy data published in peer reviewed medical or surgical journals.

Clitoral unhooding reduces or removes the skin folds over the clitoris. As an anatomy instructor at Weill Cornell Medical College, I consider clitoral unhooding an inherently risky procedure, given its proximity to the clitoral nerves and the small and vulnerable clitoris.

G‐spot amplification, another “sexual enhancement” procedure involves an injection of collagen or other bulking agent (same fillers used for facial wrinkles) into the front vaginal wall. The theory behind such an injection is to create a temporary (as collagen always absorbs and disappears) bump beneath the Grafenberg’s spot to enhance sexual response.

Sub-clitoral injections underneath the clitoris using filler bulking agents such as collagen or hyaluronic acid are purported to “lift” the clitoris, increasing exposure of the sensitive clitoral glans, allegedly to enhance sexual sensitivity.  This poorly documented procedure continues to flirt around the Upper East Side of Manhattan, offered primarily in cosmetic surgical offices.

Each of these sexual enhancement procedures carries the risk of scarring, pain, infection and numbness. Benefits are unclear, as the miniscule amount of peer-review data currently available used non-validated patient questionnaires administered by the surgeons themselves as opposed to blinded reviewers, and did not include objective measures of nerve function and other measures of genital function and sensitivity.

What say the gynecologists?

In 2007, The American College of Obstetrics and Gynecology issued a warning about all of these vaginal rejuvenation cosmetic and sexual enhancement procedures in Bulletin #378,  finding labiaplasty and perineoplasty “may be warranted in properly selected patients,” while reserving endorsement of G‐spot enhancement, the ill‐defined “vaginoplasty,” the mystery-shrouded, copiously marketed laser vaginal procedures, and clitoral unhooding, until each procedure garners the necessary peer review safety, efficacy, and technique disclosure warranted by medico-ethical standards of clinical acceptability.

For synopsis ACOG bulletin: ACOG committee opinion #378 on cosmetic gynecology

What say the plastic surgeons?

Nothing, really.

from American Society of Plastic Surgeons: ASPS weighs in on vaginal rejuvenation, sort of

There are a number of different vaginal rejuvenation procedures that can be performed by board-certified plastic surgeons. Here, an ASPS Members Surgeon explains the reasons why women may seek out procedures such as this. Learn more about cosmetic procedures.

Note: Some of the procedures and technologies presented in the following videos may be under investigation and presented for research and educational purposes. More scientific study may be needed to determine efficacy and success rate. The American Society of Plastic Surgeons (ASPS) and the Plastic Surgery Educational Foundation (PSEF) do not endorse the procedures or technologies presented nor do the statements of the individual physicians represent the opinions, positions, or recommendations of the ASPS or PSEF.

From The American College of Surgeons, The American Society of Aesthetic Plastic Surgeons and the American Academy of Cosmetic Surgeons: Zero.

Except for ASPS saying “we can do it”, these non-gynecologic surgical societies, whose vaginal rejuvenating members aggressively online advertise cosmetic gynecologic procedures, provide no medico-ethical professional statements for us to consider, despite the widespread adoption of things gynecologic into the plastic surgeon’s arena. This “plastic/cosmetic surgeon as vaginal rejuvenator” phenomenon spawned a competitive explosion in the marketing of “vaginal rejuvenation”, replete with page after page of graphic, genital BEFORE AND AFTER images, something gynecologic surgeons had never previously adopted into office, online or related marketing practice. Given the robust vaginal and vulvar enthusiasm demonstrated by many plastic and cosmetic surgeons, you’d expect their professional societies to weigh in on the ongoing vaginal rejuvenation debate with something more than “we can fix your vagina and we have the images to prove it”  regarding this controversial corner of medicine.

If you’re interested in cosmetic “vaginal rejuvenation”, begin a conversation with yourself about your motivations and perspective: Cosmetic Gynecology Personal Perspective Litmus Test

While doctors, medical societies and health advocates rage on in the debate about what is and what is not acceptable vaginal rejuvenation, each patient is fairly clear about her individual rejuvenation goals. Vaginal rejuvenation is whatever you need it to be‐ Kegel exercise to improve vaginal muscle tone, bladder control and orgasm; vaginal estrogen for lubrication and clitoral sensitivity; prolapse operations to resuspend the dropped uterus, bladder and rectum; perineoplasty to restore vaginal snugness after childbirth; minimally invasive incontinence procedures or medications for bladders not controlled by Kegel exercise alone, each available as needed to get your pelvic life back on track. The cosmetic procedures to alter the labia or hymen, and to a greater extent, the operations promising sexual ehancement, carry relatively escalated levels of scrutiny due to concerns about the medicalization of female sexuality, and the variable dearth of data regarding both safety and efficacy.

REFERENCES OF INTEREST

Medicalization of Sexuality:

Professor Leonore Tiefer Home Page

Forecasting pelvic floor disorders:

Pelvic floor disorders 2010 – 2050

Labiaplasty technique:

Labiaplasty overview and link to technique monograph

Labiaplasty technique

Clitoral unhooding and mixed genital plastic surgery:

Female cosmetic genital surgery

Multicenter study of female genital plastic surgery

Hymen restoration:

Should doctors do virginal reconstruction for adolescent girls? Cultural considerations cannot be ignored,

Reconstructing the hymen: mutilation or restoration?

Hymen reconstruction:ethical and legal issues

Perineoplasty:

Vaginal laxity and post-perineoplasty images

Perineoplasty in women with sensation of a wide vagina

Combined anal sphincteroplasty and perineal reconstruction for fecal incontinence in women.

Kegel muscles and sex:

female orgasm: role of pubococcygeus muscle

vaginal contractions in female orgasm

The Science of Sex circa 1982

Orgasm mechanics the same in women and men

(c) Lauri Romanzi, 2010

As a relentless advocate for avoiding hysterectomy unless you will truly benefit from the surgical removal of your uterus, I am here to share information about the benefits of  hysterectomy when it’s done for all the right reasons.

My favorite “don’t need a hysterectomy” message is  about uterine resuspension for treatment of uterine prolapse, a condition that accounts for about 16% of benign hysterectomies in the States, being the third most common indication for hysterectomy after fibroids and dysfunctional bleeding. Since uterine resuspension fixes uterine prolapse just as well as hysterectomy-based repairs, there is no need to undergo hysterectomy for prolapse.

But what if you’re suffering with a condition for which hysterectomy truly can make a difference?

Is there any such thing as a Happy Hysterectomy?

The Female Pelvis

Fibroids, adenomyosis, dysfunctional bleeding and endometriosis are the biggest players in this “do I or don’t I” hysterectomy arena. Let me help you understand something most of you already intuitively know – one woman’s hysterectomy blessing is another woman’s hysterectomy nightmare. What turned your neighbor’s life into a happy healthy place might not work so well for you.

According to a  beautifully designed and implemented research project recently published in the bible of gynecologic research, ”Obstetrics and Gynecology”, whether you’ll celebrate or regret your hysterectomy depends on how much headache your uterine condition is causing in terms of pain, painful sex, heavy bleeding, pelvic pressure, and fatigue from the anemia caused by heavy bleeding, combined with how you feel about your uterus, and how you feel about hysterectomy.

With the right mix of severe, recalcitrant uterine problems in the setting of unsuccessful non-hysterectomy therapies, and a laissez-faire attitude toward the role of your uterus in your version of womanhood, a hysterectomy may turn out to be best thing you ever did. But when the clinical/personal mix leaves you feeling like less of a woman and wondering why you signed up to remove an organ that plays a crucial role in your feminine identity, you may well regret your hysterectomy.

Sometimes the best clinical research just makes a lot of sense.

The March 2010 issue debuted the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA).  Taking 10 years to complete, this team of researchers from California’s Kaiser Permanente HealthCare System painstakingly kept track of over 1400 women with benign (non-cancerous) uterine and other pelvic problems as they decided to undergo hysterectomy, undergo alternatives to hysterectomy, or decide not to decide by foregoing treatment in favor of TIME, the unsung heroine of benign uterine problems. If you can hang in there until menopause starts, most likely your uterus will calm down and the symptoms will … just… slowly… stop.

At the beginning of the trial, women were asked how they felt about  the

“benefits of not having uterus”

• lack of menstruation,
• uselessness of uterus once childbearing complete,
• no more birth control concerns

the

“value of the uterus ”

• sexual function
• feeling complete as a woman

and

“hysterectomy concerns”

• feeling older
• violated
• sad about loss of fertility resulting from hysterectomy

Over the ensuing decade, these self-rated attitudes were compared to symptom impact on each woman’s overall quality of life and sexual function as she dealt with her gynecologic disorder.

Guess what they found? Among the women who chose hysterectomy, those who felt that the benefits of not having a uterus outweighed the value of having a uterus and hysterectomy concerns, or for whom the underlying condition had major impact on quality of life and sexual function (pain in daily life, uncontrollable bleeding, painful sex, constipation, irritable  bowel, overactive bladder, urinary incontinence and the like) and for whom non-hysterectomy therapies did not work who did not want to wait for natural menpause to but the brakes on the condition, reported that hysterectomy improved quality of life in a major and regret-free fashion,  including, when applicable, their sex lives.

Women for whom the underlying condition was not associated with severe impact on quality of life and sexuality, and who rated the value of having a uterus and hysterectomy concerns higher than benefits of not having a uterus were more likely to regret the hysterectomy.

Over the past 25 years many a gynecologic staple indication for hysterectomy now comes with non-hysterectomy options. Conditions include fibroids (extremely common benign smooth muscle tumors of the uterus that can make for heavy or irregular periods, pelvic pressure, colorectal and urinary difficulties, infertility and enlarged abdomen), adenomyosis (spongy super-thickening of the lining of the uterus that can cause heavy and irregular periods), and endometriosis (abnormal location of uterine lining tissue outside of the uterus itself where it does not belong, often implanting on the tubes, ovaries, intestines and other pelvic organs causing pelvic pain, scarring and infertility). These options include hormone suppression with birth control pills or hormone-containing IUD (intrauterine contraceptive device), endometrial ablation using controlled cautery of the lining of the uterus so that it doesn’t bleed very much, (http://www.nlm.nih.gov/medlineplus/ency/article/000903.htm), or shrinking fibroids using  uterine artery embolization, a radiologic procedure that threads a tube into the uterine artery through the groin, injecting embolic material that blocks bloodflow to the fibroids. (http://www.nlm.nih.gov/medlineplus/ency/article/007384.htm).

So now we’ve got choices, and they often work quite well. It used to be wait for menopause, take harsh hormones, (look up Danazol for endometriosis when you have a chance), clean out the uterus with a D&C, and if none of that worked, your options were restricted to toughing it out or hysterectomy.

Besides these new therapies, it is important to understand that not every condition needs treating. Mild endometriosis may never cause a problem short of a tendency to painful periods, or it can be as brutal as a cancer, socking onto every organ in the pelvis, ruining your fertility and making you feel like your belly’s on fire. Fibroids can be cute little nubbins scattered here and there with nary a clinical impact, or they can be gigantic super-ball-consistency uterine tumors the size of your head.  Dysfunctional bleedng tack a few extra days on to your period, or it can be a  hemorrhagic pad-soaking, anemia inducing tsunami that knocks the wind out of your life every month.

In the SOPHIA trial, of the 1400 women participating fully for the entire 10 years, only 207 (14.6%) chose hysterectomy- ”These women were more likely to report symptomatic fibroids and that they did not want to become pregnant” at the beginning of the study”. ” Women who reported higher levels of pelvic problem impact on sex or who had higher (mental stress) scores were more likely to choose hysterectomy as were women wtih higher scores on the “benefits of not having a uterus” scale and lower scores on teh ‘hsterectomy concerns” scale.  63.9% of the 207 women who chose hysterectomy were very satisfied with the results. but nearly 22% were only  somewhat satisfied, about 7% were ambivalent, with the remaining, about 8%, frankly dissatisfied.  The majority of women who used uterine artery embolization and endometrial ablation did not go on to hysterectomy, highlighting the growing role of these effective, uterine-preserving operations for conditions traditionally treated with hysterectomy.

The authors further state “Perhaps the most noteworthy are our findings regarding the significant role of women’s attitudes toward their uterus and hsyterectomy in their decision making regarding and satisfaction with this surgery.”, and “We cannot comment, however, on the extent to which these attitudes were elicited by or shared with physicians.”

Here’s the deal, if the condition is benign but truly ruining your life, and you really like your uterus, find a gynecologist who shares your perspective, and try the all appropriate non-hysterectomy therapies. For those of you who’ve already done everything BUT the hysterectomy, and the fibroids/bleeding/pain is DRIVING YOU NUTS, a hysterectomy just might make your life a lot better.

The Aging Ovary

HEADS UP: for most non-medical people, hysterectomy = remove the uterus and ovaries. The medical definition of hysterectomy, however, is removal of uterus only, ovaries LEFT IN PLACE.  Your ovaries make almost all of your sex hormones. And even if you’re menopausal, there may be some good  reasons to leave your ovaries right where they are until age 75 or so – see

http://www.ncbi.nlm.nih.gov/pubmed/20226402,

http://www.ncbi.nlm.nih.gov/pubmed/17513923,

http://www.ncbi.nlm.nih.gov/pubmed/16055568.

Really need a hysterectomy?  Make it a happy one, keep your ovaries.

I have the privelege of contributing my literature reviews to the Journal of Sexual Medicine (JSM). Below you’ll find my JSM synopsis of the SOPHIA trial:

Predictors of Hysterectomy Use and Satisfaction. Kuppermann M, Learman LA, Schembri M, Gregorich SE, Jackson R, Jacoby A, Lewis , Washington AE. Obstet Gynecol 2010 Mar, 115(3):543-551. This prospective observational Study of Pelvic Problems, Hysterectomy, an Intervention Alternatives (SOPHIA) monitored 1420 women over a 10 year period, to describe the natural history of the choice to choose or forego hysterectomy in premenopausal participants with benign clinical conditions for which hysterectomy was one management alternative. Baseline evaluation included pelvic symptom profile, quality of life scoring, sexual function and hysterectomy and uterus-related attitudes, in addition to use of Western and alternative medicine therapies. Hysterectomy and uterus related attitude evaluation included “benefits of not having uterus” (lack of menstruation, uselessness of uterus once childbearing complete, no more birth control concerns), “value of uterus (sexual function and feeling complete as a woman) and “hysterectomy concerns” (feeling older, violated, and sad about loss of fertility resulting from hysterectomy). Participants were English, Spanish or Chinese speaking women ages 31-54 at enrollment in trial. Over the 10 year period, 207 (14.6%) underwent hysterectomy, some of whom received up to 8 years of follow-up before end of trial. Approximately 64% of these hysterectomy women were very satisfied, with ~22% somewhat satisfied, and the remaining 15-16% neither satisfied or unsatisfied, ~7% of whom were dissatisfied to varying degrees. Women satisfied with hysterectomy had higher QOL and / or sexual function impact from the condition for which hysterectomy was performed, in addition to higher scores on the “benefits of not having a uterus” and lower scores on the “value of having a uterus” and “hysterectomy concerns” questions. The authors describe a greater likelihood to undergo and be satisfied with the outcome hysterectomy in women reporting greater pelvic problem impact on sexual function and pelvic problems overall, underscoring “the importance of determining the extent to which symptoms interfere with QOL and sexual function when counseling patients about hysterectomy and its outcomes”. The majority of women who underwent alternative therapies such as endometrial ablation and uterine artery embolization, did not go on to hysterectomy. The data clearly demonstrate the conclusion that “women’s attitudes toward their uterus and hysterectomy play a primary role in the decision to undergo and personal satisfaction with the outcome of hysterectomy” for benign conditions. Level of Evidence: IIa

The uterus comes with dual support, one robust uterosacral ligament on each side, holding it in place at the top of the vagina.

Repeat after me… Resuspend – Do Not Remove.  Hysterectomy is not a cure for prolapse, Hysterectomy is a cure for having a uterus.  There are three basic categories of uterine resuspension:

#1: Suspend the uterus to one or both adjacent sacrospinous ligaments

Sacrohysteropexy: Resuspend with an "artifical uterosacral ligament" graft

  For more details click on the role of Kegel exercises in uterine prolapse, click this interview link:

Dr. R for Sweet Talk on the Spot – Prolapse Part 2

And if you absorb nothing else, retain this: When it comes to prolapse, the uterus is a victim, not a perpetrator. Prolapse occurs because the ligaments supporting the uterus gave way, not because the uterus is heavy.  Uterine resuspension (hysteropexy) works just as well as do prolapse repairs where the uterus is removed (hysterectomy).  Durability is essentially the same. There is zero advantage to removing the uterus to repair prolapse. However, if you have prolapse and also suffer a separate,  good reason to consider hysterectomy, such as severe fibroids or endometriosis or high personal risk for gynecologic cancers, there may be a true benefit to removing the uterus at the time of prolapse repair.  Otherwise, lift that uterus up into normal position with a resuspension procedure and get on with your life! 

To find a surgeon to do your uterine resuspension in your area,  visit http://www.mypelvichealth.org/FindaProvider/tabid/75/Default.aspx and ask your regional specialists if they are comfortable and experienced with uterine resuspension for uterine prolapse.

Summertime is high season for gardening.  Pregnant gardeners need to take extra precautions to avoid chloasma and melasma (dark blotches) on the face and neck, protect backs, knees and pelvic support, and avoid gardening aids that may be toxic if inhaled or coming in contact with skin.  For the full scoop on healthy gardening while pregnant read this piece from www.sheknows.com, including content from Dr. R:

Gardening during pregancy – your skin, your joints, your pelvis, your baby!

(c) Amy Wentz

Dr. Romanzi, 19 years ago I gave birth to my daughter, and while she was being delivered I was torn from my vaginal opening to my anus. The Dr. didn’t repair the torn skin correctly, and I am very self conscious about this. I also have a very hard time wipeing my BM all the way. Is their anything that can be done for this?

Thank K

Dear K,
Even with correct technique at the time of delivery these deep tears often don’t heal perfectly due to the swelling and hormonal changes in skin and deep connective tissues during pregnancy and delivery that result in less than optimal healing from childbirth tears. That said, it is very likely that your anatomy and function can be restored or significantly improved with reconstructive surgical repair of the perineum (perineoplasty) and/or anal sphincter (anal sphincteroplasty). Sometimes perineoplasty alone is enough. Whether one or both procedures might be advised can only be determined through clinical examination, after which various other imaging and colorectal tests might be advised to determine the optimal procedure(s) for your personal situation. It’s been 19 years! Pull this up to the top of your priority list and get the information you need. Thanks for sharing your story. Please keep us posted!

Dr R

Dear Dr. Romanzi,
I recently finished your book and found it quite informative. I had my first baby when I was 35, pitocin-induced with no pain medication. After a short but extremely intense labor, my labia tore off and although the doctor tried to repair it, it doesn’t feel (or look) quite right and seems to flap open all the time. I also feel like my vagina is a wind tunnel, especially when I do yoga–it makes a lot of noises. Ever since the birth I have suffered from stress incontinence but I’m not sure if I have prolapse. Several doctors have told me I am too young for a sling or surgery and simply recommended kegel exercises. I’ve tried kegels and even got the Myself (a biofeedback system) and nothing has improved my incontinence. I am now 38 and 20 weeks pregnant (not planning any other pregnancies). How soon I can get these issues fixed after I deliver? Do you think I am too young for a sling?

Dear Reader,
No one is “too young for a sling”, provided they suffer significant stress urinary incontinence. Two categories of incontinence apply to most women with bladder control problems, those being stress (”exert and squirt” leaking with cough, sneeze, lift, running, etc) and urge (overactive bladder, urination before seated on toilet), and about 1/3 of women with incontinence have a little of both problems.
Kegels are a good therapy for both types of incontinence in about 70% of cases, including mixed stress/urge. Once you’ve birthed the baby, you may be well served to spend 12 weeks working properly wtih a pelvic floor physical therapist rather than on your own with or without a Kegel exercise gadget. It’s like working with a personal trainer, typically yielding better results. If this fails, you may need medications or electric stimulation for urge incontinence, and a sling for stress incontinence. Slings do not reliably improve urge incontinence, an important distinction should a sling be recommended for you – it is likely that overactive bladder symptoms will persist after a sling, with the “exert and squirt” symptoms gone, or significantly reduced.
The vaginal laxity may also respond to Kegel exercise because the exercises can bulk up the vaginal muscles, making for snugger inner contour. If this does not work, reconstructive surgery may be done with or without concomitant sling, and your labum can be repaired at the same time. The exact best procedure for you, however, can only be determined with a proper pelvic support examination and bladder function testing.
Typically, women are advised to complete childbearing before undergoing reconstructive surgery for laxity, prolapse and stress incontinence, since pregnancy after said operation(s) may undo the results.
Thank you for sharing you story!
Best Regards, Dr R

Dr. R, I wrote to you about a month ago. I did decide to go ahead and have the Laproscopic Bilateral(other part of hysterectomy) done. I had the partial in 2000. I had it done one week ago today. I am feeling much better. Little pain in the navel area. Some “hot flashes” ocurring in the early hours of the morning for a few minutes and then they go away. My doctor said that the surgery went well and I am to follow-up with him in about 3 weeks. Dr. R, I hear some women say that they lost their drive for sexual intercourse. Does this happen in all women who have total hysterectomies or does it depend on the female. I am a little nervous about this. I have been married 18 1/2 years and my husband is a wonderful man. What advice do you have now that all my plumbing is gone. Thanks for your previous response to my question in April. I really love your website. God Bless R (Alabama)

Dear R from Alabama,
We are learning more every day about women’s sexuality, and we have found that a variety of hormones definitely contribute to sex drive. Some of these hormones are produced by the ovary, while others come from the adrenal glands (on top of your kidneys) and others come from your brain. Chances are your sex drive will be just fine, possibly better now that the source of pelvic pain is gone, along with the worry. The love and stability in your relationship trumps all, as this is the sexiest of sex drive factors.
Thank you for getting back to us and sharing your story.
Dr. R