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Endometriosis is a condition in which the endometrium – the tissue that lines the inside of the uterus – grows abnormally elsewhere. Common locations include the ovaries, fallopian tubes, outer surface of the uterus, and other pelvic organs and connective tissues. The endometrium may also grow into the muscular wall of the uterus, in which case, the condition is known as adenomyosis.
The endometrium is a special tissue, it undergoes periodic changes with each menstrual cycle. Each month, under the influence of estrogen, the lining of the uterus grows and thickens, in preparation for the possibility of pregnancy. If fertilization does not take place, the tissue breaks down and is shed in menstrual bleeding, and the cycle starts over.
In endometriosis, the displaced endometrial tissue behaves the same way, but the blood has nowhere to escape. It irritates the surrounding tissues, causing inflammation, scarring, and possibly adhesions. Depending on the location, endometriosis may cause a range of symptoms and problems, but the most common complaint is pelvic pain, which can be of various kinds. Symptoms can be very different from person to person.
Endometriosis is very common. It is estimated that about 10% of women of reproductive age have some degree of endometriosis. Higher risks are observed in women who have: never had children, started periods at an early age, heavy periods that last longer than usual, shorter cycles, relatives with endometriosis, or abnormalities in the reproductive organs.
Endometriosis usually develops several years after the start of menstruation. The condition may temporarily improve with pregnancy and may go away with menopause.
Diagnosis is usually based on symptoms, but because most symptoms are not specific, other conditions that may produce similar symptoms must be first ruled out. Pelvic exams and imaging tests also help, but only a biopsy, obtained by means of surgery, can give a definitive diagnosis.
While endometriosis is not a cancer and usually not life-threatening, it may cause infertility and/or unbearable symptoms in some women.
Treatment options include:
– Pain medication, such as ibuprofen.
– Hormone therapy, such as birth control pills, to help control endometrial growth and prevent new implants. This, however, only works for as long as the medication is taken, symptoms usually return after treatment is stopped.
– Surgery to remove endometrial implants may provide a definitive cure for severe endometriosis. It may also improve fertility provided that the reproductive organs remain intact.

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Menopause marks the end of reproductive years in a woman’s life, when menstrual periods stop permanently. Menopause usually occurs naturally, as a result of declining levels of reproductive hormones, estrogen and progesterone, produced by the ovaries; but it may also happen prematurely after surgical removal of the ovaries, as a side effect of cancer treatments, or in a condition known as primary ovarian insufficiency, where the ovaries fail to produce hormones.
Menopause is usually preceded by a transient period called perimenopause, when hormone levels start to drop. The last couple of years leading to menopause may bring symptoms such as hot or cold flashes, mood swings, insomnia, vaginal dryness, urinary urgency, and dry skin. Some women may also experience temporary heart racing, headaches and hair loss. The most telling sign that menopause is approaching is the irregularity of periods. Skipping a period or two is common. The cycles may also be shorter. Periods may be heavier or lighter than usual.
Most symptoms usually ease in the years after menopause, but low levels of estrogen may cause other health problems. Because estrogen influences bone density and has a protective action on blood vessels against cholesterol plaques, low estrogen levels increase risks for bone loss, known as osteoporosis, and cardiovascular diseases. Low estrogen also weakens the tissues supporting the urethra, causing urine leakage, or urinary incontinence. Risks for urinary tract infections also increase after menopause.
While menopause is a natural stage of life and does not require medical treatment, it is important to maintain a healthy lifestyle including physical exercise and diets sufficient in calcium and vitamin D, to counter the risks of heart diseases and osteoporosis. Women with persisting or severe symptoms may also benefit from certain treatment options:
– Topical estrogen in the form of cream, tablet or ring, administered directly to the vagina, can be effective for treatment of vaginal dryness and urinary problems.
– Kegel exercises strengthen pelvic floor muscles and may help treat urinary incontinence.
– Estrogen replacement therapy is effective for treatment of severe hot flashes and may help prevent osteoporosis. However, it is associated with higher risks for cardiovascular diseases and breast cancer, and should be considered only for women with high risks of osteoporosis who cannot take non-estrogen medicines. Hormone therapy should be used at the lowest dose for the shortest duration needed to achieve treatment goals.

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Pelvic organ prolapse is a group of conditions in which one or more pelvic organs drop from their original position into or out of the vagina. Normally, the pelvic organs are held in place by the pelvic floor muscles. Prolapse happens when these muscles are weakened and can no longer offer proper support. A prolapse can be of different degrees, ranging from mild to severe. More than one organ may be affected at the same time.
Most commonly, the pelvic floor muscles weaken as a result of pregnancy and childbirth, especially vaginal birth, but the impairment can also be caused by aging, obesity, previous pelvic surgeries, and conditions that increase abdominal pressure on a regular basis, such as chronic coughing, or constipation.
Common types of prolapse include:
– Prolapse of the urinary bladder, called cystocele
– Prolapse of the uterus, or uterine prolapse
– Prolapse of the rectum, called rectocele
– And dropping of the top portion of the vagina toward vaginal opening, called vaginal vault prolapse. This type commonly happens after surgical removal of the uterus, which normally holds the vaginal vault in place.
A prolapse can be very uncomfortable and may cause pain or pressure in the pelvis or lower back. Depending on the organ that is affected, symptoms may also include urinary problems, constipation, or painful sex.
Treatments usually start with pelvic floor exercise, such as Kegel exercise, to strengthen the muscles. Biofeedback techniques may be used to help patients identify and squeeze the right muscles.
In post-menopausal women, low estrogen levels may be responsible for the weakening of pelvic floor muscles. In this case, a vaginal estrogen supplement can be effective as treatment.
A silicone device called a pessary can be deployed vaginally to hold the prolapsed organs in place. Pessaries are available in a variety of sizes and shapes. They are removable and should be cleaned regularly.
Surgeries may be performed to repair the tissue bulge, but recurrent prolapse is common after a surgery, because it doesn’t repair the underlying weakened muscles. There are several types of surgeries, for different types of prolapse. The most commonly performed are: removal of the uterus to correct uterine prolapse; and attachment of the vaginal vault to certain structures in the pelvis, to repair vaginal vault prolapse.

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Birth control pills are medication used to prevent pregnancy. They contain hormones that suppress ovulation. The most effective type is the combination pill which contains both estrogen and progestin – a synthetic form of progesterone. These 2 hormones interfere with the normal menstrual cycle to prevent ovulation.
The menstrual cycle refers to the monthly events that occur within a woman’s body in preparation for the possibility of pregnancy. Each month, an egg is released from an ovary in a process called ovulation. At the same time, the lining of the uterus thickens, ready for pregnancy. If fertilization does not take place, the lining of the uterus is shed in menstrual bleeding and the cycle starts over. The menstrual cycle is under control of multiple hormones secreted by the hypothalamus, pituitary gland, and ovaries. Basically, the hypothalamus produces gonadotropin-releasing hormone, GnRH; the pituitary secretes follicle-stimulating hormone, FSH, and luteinizing hormone, LH; while the ovaries produce estrogen and progesterone. These hormones are involved in a REGULATORY network that results in monthly cyclic changes responsible for ovulation and preparation for pregnancy.
The 2 hormones that are required for ovulation are: FSH, which starts the cycle by stimulating immature follicles to grow and produce a mature egg; and LH, which is responsible for the release of the egg from the ovary – the ovulation event itself. Two other hormones, estrogen and progesterone, are at high levels after ovulation, in the second half of the cycle. They suppress FSH and LH during this time, preventing the ovaries from releasing more eggs. If fertilization occurs, estrogen and progesterone levels REMAIN HIGH throughout pregnancy, providing a continuous suppression of ovulation. On the other hand, in the absence of pregnancy, their levels FALL, causing menstrual bleeding.
The levels of estrogen and progesterone in the combination pills mimic the hormonal state after ovulation, tricking the ovaries into thinking that ovulation has already occurred; FSH and LH are constantly suppressed, no egg is matured or released.
The pills are taken every day for three weeks, followed by one week of placebo pills containing no hormones. During the week of placebos, estrogen and progesterone levels fall, triggering a so-called withdrawal bleeding, or fake periods. The bleeding serves as a convenient indication that fertilization did not happen, but it is not required for birth control. In fact, there exist continuous-use contraceptive pills with less or no placebos, resulting in less or no menstrual periods. These pills are particularly beneficial for women who suffer from menstrual disorders such as excessive menstrual bleeding, painful menstruation and endometriosis.
For lactating women, or those who cannot tolerate estrogen, there are mini-pills that contain only progestin. These are not as effective as combination pills at preventing ovulation. Their effect relies more on the ability of progestin to promote secretion of a thick cervical mucus to obstruct sperm entry.

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The placenta is the organ that connects the fetus, via the umbilical cord, to the uterine wall of the mother. This is where the exchange between maternal and fetal blood takes place. The placenta provides the fetus with oxygen and nutrients and takes away waste such as carbon dioxide. Normally, it attaches at the top or side of the uterus. At birth, it is delivered AFTER the baby, in the third stage of labor.
Placenta previa, or sometimes referred to as LOW-lying placenta, is a pregnancy complication in which the placenta attaches to the LOWER end of the uterus, NEAR or COVERING the cervical opening. Placenta previa can be classified as complete or marginal.
The main symptom is painless bleeding in the second half of pregnancy. As the lower part of the uterus gradually THINS in preparation for the onset of labor, placental attachment is disrupted resulting in bleeding.
Risk factors for development of placenta previa include:
– previous pregnancies
– previous surgeries of the uterus
– previous placenta previa
– carrying more than one fetus
– maternal age of 35 or older
– smoking and cocaine use
The location of the placenta is usually checked during a routine ultrasound mid-pregnancy, but a low-lying placenta at this point may NOT be a cause for concern. In most cases, the placenta grows toward the richer blood supply in the upper uterus as the uterus expands in the third trimester. Only about 10% of all low-lying placentas persist until delivery. A placenta that completely covers the cervix is more likely to stay that way than one that’s bordering it.
Placenta previa presents significant risks to both the mother and the baby. A cesarean delivery is usually indicated because the placenta may block the birth canal completely, or bleed profusely during labor as the cervix dilates. The mother may experience excessive blood loss and the baby may suffer from hypoxia as a result of INadequate blood supply.
The goal of treatment is to manage bleeding to get as close to the due date as possible. In case of little or no bleeding, bed rest and pelvic rest are recommended. Heavy bleeding is an emergency and might require a blood transfusion. If delivery is necessary before 37 weeks, corticosteroids may be given to help the baby’s lungs develop. An uncontrollable bleeding would require an emergency C-section even if the baby is premature.

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An ectopic pregnancy is a pregnancy that occurs outside the uterus. Normally, fertilization takes place in the widest section of the fallopian tube. The fertilized egg then travels toward the uterus where it is to be implanted. Ectopic pregnancy happens when the egg gets stuck on its way and starts to develop inside the tube. This is known as tubal pregnancy. Implantation may also occur in the cervix, ovaries and abdominal cavity but tubal pregnancy is by far the most common. With extremely rare exceptions, the fetus cannot survive outside the uterus. Without treatment, the growing tissue may rupture, resulting in destruction of the surrounding maternal structures and a massive blood loss that could be life-threatening.

Signs and Symptoms 

An ectopic pregnancy may have no signs, or may feel like a normal pregnancy at first, with positive pregnancy test result for hCG. First clinical symptoms usually appear after 4 weeks from the last normal menstrual period and may include abdominal pain, vaginal bleeding, or both. There may also be shoulder pain. If the fallopian tube ruptures, heavy bleeding, fainting and shock can be expected. This is a medical emergency and requires immediate attention.

Causes

Tubal pregnancy occurs because of problems in transportation of the fertilized egg through the tube. Fallopian tubes are lined with hair-like structures called cilia that help to move the egg through. It is believed that a reduction in number of cilia may slow down the transport and lead to tubal pregnancies. Cilia degeneration can happen as a result of tubal tissue scarring or as an effect of certain chemicals or drugs.

Risks factors include:

-Inflammation of fallopian tubes – salpingitis; or infection of pelvic organs – pelvic inflammatory disease. These infections are commonly caused by gonorrhea or chlamydia.
-Use of an intrauterine device as a contraceptive method
-Tubal or intrauterine surgeries such as tubal ligation, tubal reversal and dilation & curettage
-Previous ectopic pregnancy
-Abnormal fallopian tubes due to birth defects
-Smoking
-Exposure to certain fertility drugs
-Daughters of mothers who have taken the synthetic estrogen diethylstilbestrol during pregnancy

Diagnosis is often based on blood tests for hCG and a transvaginal ultrasound.
If the ectopic pregnancy is detected early, methotrexate may be injected to dissolve the pregnancy tissue. In other cases, a keyhole surgery may be performed. If the fallopian tube has ruptured, an emergency open surgery is required. The ruptured tube is usually removed. After treatment the hCG levels are monitored to ensure that the entire ectopic tissue has been taken out. An hCG level that remains high would require further treatment.