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Conditions

At CEAPS, we diagnose and treat various complex gynecological conditions. We believe in taking a patient-centered approach, focusing on the patient’s experience to provide different options with optimal treatment plans for their specific condition. Dr. Moawad advocates for patients to help them understand their conditions and empower them to make informed decisions.

Adenomyosis

Adenomyosis is defined as ‘the presence of endometrial glands and stroma found within the muscle of the uterus or myometrium. During monthly menstruation, this embedded tissue bleeds and can lead to intense pelvic pain, inflammation and swelling, and heavy bleeding.

This condition is oftentimes misunderstood or even misdiagnosed, as Adenomyosis, often referred to as Endometriosis of the muscle of uterus, causes both painful and heavy periods, painful sex, or dyspareunia.

With Endometriosis, spots of endometrial lining are located outside of the uterus, while in the case of Adenomyosis, this tissue is inside the muscle of the uterus… or an “Inside-Out Endometriosis”, as it used to be known.

To date, there are no clear causes of Adenomyosis, which can be frustrating. Studies have shown that people who have given multiple births and who already suffer from Endometriosis are more at risk for Adenomyosis.

To diagnose Adenomyosis, a doctor will examine you and assess your symptoms. With this condition, the uterus may feel big, soft, tender, and very sensitive to the touch.

Tests that can be performed by your doctor are:

  • Ultrasound
  • MRI
  • Pathology examination after a Hysterectomy procedure

As far as treatment goes, the symptoms of Adenomyosis can be dealt with by taking pain medication or by preventing monthly menstruation with hormonal treatment:

  • Pain medication: The pain associated with Adenomyosis can be debilitating. Analgesics, anti-inflammatories, or strong painkillers can be prescribed.
  • Hormonal Treatment: This is not a cure, as the pain will return if the treatment is stopped. Oral contraceptive pills and contraceptive implants (hormonal IUD), or injections can be suggested by your doctor to relieve pain and stop monthly periods.
  • Surgery: If Adenomyosis is localized, it could be surgically excised. Sometimes the only solution to Adenomyosis is to remove the entire uterus. This procedure is called a Hysterectomy and may be suggested by your doctor based on your medical history, extent of pain, and other symptoms.

 

Cervical Insufficiency

Cervical Insufficiency, also known as Cervical Incompetence is the inability of the uterine cervix to retain a pregnancy in the absence of contractions in the second trimester. With this condition, the cervix begins to dilate and thin before the pregnancy has reached term. Cervical insufficiency can occur in a single pregnancy, or may be recurrent.

It has profound implications for both maternal and neonatal outcomes, including losing a pregnancy, premature delivery and prolonged bed rest during pregnancy.

Cervical Insufficiency can be caused by one or more different factors, including:

  • Previous surgery performed on the cervix
  • Damage to cervix during a previous difficult child birth
  • Birth defect resulting in a malformed cervix or uterus
  • Trauma to the cervix from procedure to terminate a miscarriage
  • Exposure to DES (Diethylstilbestrol)

If you have had a miscarriage after your second or third trimester, your doctor may check for Cervical Insufficiency. You may also undergo an ultrasound before pregnancy or early on in your pregnancy if you have any potential risk factors for this condition.

Your doctor will examine you through:

  • Ultrasound
  • Pelvic exam

The treatment for a Cervical Insufficiency is a procedure to close and reinforce the opening in the cervix. This is performed between 14-16 weeks of the pregnancy, or could be done before the pregnancy.  This procedure is called a Cervical Cerclage and is performed primarily through vaginal route. In case of failure of the cerclage or inability to perform through the vaginal route, an abdominal approach is then preferred. This procedure is called a Transabdominal Cerclage, also known as a TAC.

At CEAPS, Dr Moawad’s extensive research on the subject, and his advanced training in performing these procedures, enables patients to have a successful, less morbid minimally invasive procedure with a high success rate.  

Fibroids

Fibroids are non-cancerous growths consisting of muscle and fibrous tissue located inside the uterus and varying in size. Some Fibroids are just a few inches big, and others may take up the whole abdominal cavity.

Fibroids are quite common in people of reproductive age, affecting 85% of women. Most Fibroids usually go undetected and cause no symptoms, though Fibroids can cause a variety of symptoms including abnormal vaginal bleeding, abdominal and pelvic pain ….

Fibroids are named depending on their location:

  • Subserous Fibroids: Grow in the muscle of uterus, expanding outside the uterus into the pelvic area
  • Intramural Fibroids: Grow within the muscle of the uterus
  • Submucosal Fibroids: Grow towards the inner wall and expand in the the endometrial cavity

Generally speaking, Fibroids, no matter their type, grow slowly. However, among many factors, high levels of Estrogen can make these Fibroids grow faster.

Typically, Fibroids are benign tumors. They could, although rarely become cancerous, with this only happening in between 1 in 500 and 1 in 2000 people.

As mentioned, most people with Uterine Fibroids experience no symptoms. However, 1 in 3 people with Fibroids experience symptoms, mostly related to the size and the location of the Fibroids.

These symptoms include:

  • Heavy bleeding during periods with blood clots and cramps
  • Abdominal or lower back pain
  • Frequent need to urinate
  • Constipation
  • Deep pain during sex
  • Infertility or difficulty conceiving

Any person of reproductive age can get Fibroids, from puberty on to menopause. Because their growth is related to the hormone Estrogen, Fibroids can potentially shrink away after the onset of Menopause.

To diagnose Fibroids, your doctor will ask for a medical history and a pelvic exam. Large Fibroids can be detected through vaginal or abdominal examinations.

Tests to detect Fibroids may include:

  • Blood tests to detect anemia associated with heavy periods, a symptom of Fibroids
  • Utrasound
  • MRI

Treating your Fibroids will depend on the symptoms associated with this condition. It also depends on their size, location, and your future plans for fertility.

Most of the time, Fibroids can be left untouched and just monitored. You may be prescribed medication to treat symptoms of pain or heavy periods. Other times, Fibroids might need to be surgically removed. This is a shared decision that you can make with your doctor based on your evaluation.

Abnormal Uterine Bleeding (AUB)

AUB, Abnormal Uterine Bleeding, or sometimes referred to as Abnormal Vaginal Bleeding, is a term used to refer to heavy periods or bleeding in between normal periods. It is a common condition affecting around 10% to 20% of women in the US.

Menorrhagia, also known as heavy periods, occurs when there is loss of excessive blood during monthly menstrual cycles.

Metrorrhagia, also known as bleeding between periods, occurs when there is bleeding from the uterus between menstruations.

AUB is not just uncomfortable and inconvenient, but it can also affect the person’s quality of life whether physical, mental, or emotional.

This condition is not always associated with physical abnormalities. Approximately 40% to 60% of people with heavy periods have no specific underlying cause.

AUB is associated with:

  • Leaking through sanitary pads
  • Necessity for double protection
  • Flooding of menstrual blood onto clothes
  • Large clots in blood
  • Sensations of weakness, tiredness
  • Anemia
  • Planning daily life around menstruation

Although the majority of people with AUB have no specific underlying cause, there are some known reasons :

  • Polyps: non-cancerous growths in lining of the uterus
  • Endometriosis: when developed in the vagina and/or the lower uterus
  • Fibroids: benign growths on the walls of the uterus
  • Adenomyosis: when glands from uterus lining embed in the muscle of the uterus
  • Cancer: uterine cancer is uncommon but can cause heavy periods
  • Thyroid disease: thyroid disease can cause tiredness, weight gain, changes in hair and skin, intolerance to cold, and AUB
  • Clotting problems: platelet problems or certain diseases can affect clotting and increase AUB
  • Medical treatments: some medical treatments such as hormonal contraceptives, anticoagulants, and anti-cancer drugs can cause AUB

Rather than just identifying AUB, your doctor will probably want to investigate the causes.

Your doctor can ask for some tests, which include:

  • Blood tests
  • Ultrasound
  • Hysteroscopy (a camera to visualize the cavity of the uterus)

As for treatments, there are many options available, including:

  • Hormonal and non-hormonal treatments
  • Endometrial ablation
  • Minimally invasive surgical removal of fibroids and polyps
  • Hysterectomy

Ovarian Cysts

Ovarian Cysts are growths developing within the ovaries. Most Ovarian Cysts are harmless and are not cancerous. Cysts on the ovaries can sometimes grow as big as a watermelon, where a normal ovary is around the size of an almond.

Ovarian Cysts are most common before Menopause, occurring in around 7% of women.

Although Ovarian Cysts are not necessarily harmful or cancerous, they should be taken seriously, because they could indicate other underlying conditions. Identifying and examining Ovarian Cysts is necessary to rule out cancer and any underlying causes, such as Endometriosis.

Ovarian Cysts can come in many different forms, each with a different cause:

  • Functional cyst: These cysts form because of normal function of the ovaries. When ovulation does not happen and a follicular cyst remains in the ovaries, and the opening where the egg escapes is closed off with accumulated fluid.

  • Pathological cyst: These cysts form because of disease, but are not necessarily cancerous.

  • Dermoid cysts: These cysts grow with the existence of developmental tissue that can contain teeth, bone, or hair.
    • Hemorrhagic cysts: These cysts form due to bleeding.
    • Endometriomas: These cysts are caused by Endometriosis, and are a sign of a severe form of the condition, accompanied with a lot of pain.
    • Cancerous cysts: These cysts are rare, but commonly affect post-menopausal people, with vague symptoms that can go undiagnosed.

With Ovarian Cysts, most symptoms are not always noticeable. With Endometriomas however, the main symptom is severe pain, even when the cysts are small in size.

If the cysts are large, regardless of their type, symptoms can include pain and swelling in the abdominal area. Cysts can also lead to constipation or frequent urination due to the cysts pressing on other organs in the abdomen.

Complications of Ovarian Cysts can include twisting of the ovary, bleeding, or bursting of cysts, which can cause severe pain and bleeding, usually requiring emergency attention and treatment.

Diagnosing Ovarian Cysts can be done through assessing medical history and by examination. These tests include:

  • Ultrasound
  • Blood tests
  • MRI
  • CT scan

Some cysts should be monitored by your doctor, while others don’t need monitoring at all. Functional Cysts may go away on their own, without being treated.

Some cysts require surgery, and this should be determined by your doctor, depending on the size, appearance, test results, and symptoms.

Painful Sex

Painful sex, also known as dyspareunia, is an issue that affects around 10% to 20% of women in the US. This condition may leave some people feeling embarrassed, upset, or ashamed.

While it is normal to have anxieties over such an intimate part of your life, in most cases, Painful sex can be solved through treatment.

With both physical and emotional factors at play, Painful sex issues should be identified and assessed by a specialist, so that you can get the help you need and resume comfortable and pleasurable intimacy.

With Painful sex, it is important to be able to locate and describe the pain you are facing. Different types of pain can be associated with different underlying issues. Assess whether the pain is superficial or deep, if pain during sex is a new occurrence, if inserting a tampon hurts, and how the pain feels in general.

Once you have identified the pain, seek your doctor’s help to pinpoint the causes and potential treatments and solutions.

Painful sex can be caused by various factors, both physical and emotional.

Superficial Dyspareunia, also known as Pain on penetration is pain experienced upon vaginal entry and can be caused by:

  • Too little lubrication from menopause and thinning of the walls of the vagina
  • Injury, infection, irritation
  • Vaginismus: spasms of the muscles of the vaginal wall, making penetration extremely painful
  • Vestibulitis: inflammation of the tissues surrounding the entrance to the vagina which can cause intense pain, stinging, and soreness when pressure is applied
  • Birth abnormalities

Deep Dyspareunia, also known as deep pain is experienced after initial penetration. It can feel worse upon thrusting or in certain sexual positions, and can be caused by:

  • Endometriosis: when developed behind the vagina or the lower uterus
  • Pelvic Inflammatory Disease: caused by sexually transmitted infections
  • Fibroids: benign growths on the walls of the uterus
  • Adhesions: when organs in the pelvic area are scarred and stuck together
  • Prolapse: when the uterus drops into the vagina due to pelvic floor weakness

To identify and asses your condition, the doctor will ask for details and information on your experience with painful sex, including history, occurrences, and type of pain. Your doctor may also perform a pelvic examination and order tests such as labs and an ultrasound.

Endometriosis

Endometriosis a condition defined by the presence of endometrial-like tissue outside the uterus.

Endometriosis affects the lining of the pelvis (peritoneum), the fallopian tubes, the ovaries and the uterus. It could also affect other pelvic structures like the bladder, the bowels and the pelvic nerves, and could grow outside the pelvis, affecting the lungs, diaphragm, etc.…

1 in every 10 women is affected with Endometriosis during their reproductive years. Although it is a common condition, it is sometimes misdiagnosed or mistreated, taking up to 7 years from the onset of pain to diagnosis.

There are multiple risk factors for Endometriosis that have been identified, however this information must be treated carefully and with caution, as knowledge about the causes and development of Endometriosis is not yet definite. Research is still ongoing to determine what the causes may be.

These risk factors may include:

  • Family history of Endometriosis
  • Never having given birth
  • Short periods
  • Heavy and long periods
  • Low BMI
  • History of high estrogen production
  • Late menopause
  • Early onset of period
  • Reproductive system irregularities

Although sometimes people with Endometriosis can be asymptomatic, many people do experience painful and uncomfortable symptoms, such as:

  • Painful periods
  • Pelvic pain throughout the cycle
  • Intestinal pain
  • Fatigue and unease
  • Painful sex
  • Difficulty conceiving and infertility
  • Painful urination or bowel movements
  • Blood in urine or bowel near the time of menstruation
  • Pain radiating into back, down legs, and sometimes into chest
  • Shoulder and neck pain
  • Fatigue
  • Dizziness with cycle
  • Recurring constipation/diarrhea

To identify and diagnose Endometriosis, we can perform the following examinations:

  • Pelvic examination
  • Ultrasound
  • MRI
  • Laparoscopy

Endometriosis can be classified in stages:

  • Stage One: Minimal Endometriosis

Characterized by minimal superficial lesions and no significant adhesions

  • Stage Two: Mild Endometriosis

Characterized by superficial and deep lesions with no significant adhesions

  • Stage Three: Moderate Endometriosis

Characterized by multiple deep lesions, small cysts on ovaries, and translucent adhesions

  • Stage Four: Severe Endometriosis

Characterized by severe and multiple deep lesions, large cysts on ovaries, and dark adhesions

These stages are based on the location, adhesions, spread, and depth of the Endometriosis and will be determined by your doctor upon examination.

If you have been diagnosed with Endometriosis, there are different treatment options, depending on the stage, symptoms and condition. For some people this disease is manageable, while for others, it is debilitating and causes disruption of daily life and routines.

Treatment can include painkillers for mild conditions, or a minimally invasive surgical excision of Endometriosis.

Endometriosis excision is when the endometriotic lesions are removed surgically while preserving the uterus, fallopian tubes, and ovaries. This type of minimally invasive surgery is the most effective treatment for Endometriosis, and should only be done by trained specialists.

People with severe deep infiltrating Endometriosis benefit highly from excision surgery. The improvement after this procedure for people with such cases is usually striking and highly successful.

Other treatments for Endometriosis include:

  • Pelvic floor physiotherapy
  • Pelvic floor Botox
  • Change in diet
  • Acupuncture
  • Assessing and avoiding environmental triggers

Cervical Insufficiency

Cervical Insufficiency, also known as Cervical Incompetence is the inability of the uterine cervix to retain a pregnancy in the absence of contractions in the second trimester. With this condition, the cervix begins to dilate and thin before the pregnancy has reached term. Cervical insufficiency can occur in a single pregnancy, or may be recurrent.

It has profound implications for both maternal and neonatal outcomes, including losing a pregnancy, premature delivery and prolonged bed rest during pregnancy.

Cervical Insufficiency can be caused by one or more different factors, including:

  • Previous surgery performed on the cervix
  • Damage to cervix during a previous difficult child birth
  • Birth defect resulting in a malformed cervix or uterus
  • Trauma to the cervix from procedure to terminate a miscarriage
  • Exposure to DES (Diethylstilbestrol)

If you have had a miscarriage after your second or third trimester, your doctor may check for Cervical Insufficiency. You may also undergo an ultrasound before pregnancy or early on in your pregnancy if you have any potential risk factors for this condition.

Your doctor will examine you through:

  • Ultrasound
  • Pelvic exam

The treatment for a Cervical Insufficiency is a procedure to close and reinforce the opening in the cervix. This is performed between 14-16 weeks of the pregnancy, or could be done before the pregnancy.  This procedure is called a Cervical Cerclage and is performed primarily through vaginal route. In case of failure of the cerclage or inability to perform through the vaginal route, an abdominal approach is then preferred. This procedure is called a Transabdominal Cerclage, also known as a TAC.

At CEAPS, Dr Moawad’s extensive research on the subject, and his advanced training in performing these procedures, enables patients to have a successful, less morbid minimally invasive procedure with a high success rate.  

Call us or request an appointment with Dr. Gaby Moawad to address your condition.

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