Atypia Is NOT An Absolute Indication For Hysterectomy

Question:

Hi Dr. Ramirez,

I'm a Canadian, temporarily living in South Africa. Greetings from Pretoria!

I'm 44 yrs old, diagnosed with PCOS at age 33, on metformin 500mg 2/day since then. I've got about 45 pounds to lose and have been slowly and steadily losing pounds since May (5 kg). I've never been able to get pregnant and throughout my 20s and early 30s, I went months without menstruation. Weight came on very quickly. I exercise regularly.

My new gyne here found a myoma in my uterus in August during my yearly exam. I had bleeding between periods almost every day for a few months. Some days it was spotting; other days it was heavier. The myoma was removed hysteroscopically and examined. The biopsy of the tumour shows atypical cells and the lab report summarizes the microscopy as "these features are most suggestive of an adenomyomatous (endometrial) polyp with focal atypia against the background of a proliferative endometrium."

I understand I need to remove my uterus.The doctor can do the surgery vaginally. Is uterus removal the best course of action? What can I do to prepare my body for no uterus? And Is there anything I can do to protect my ovaries going forward?

Thanks for your help in advance. S. from South Africa

Answer:

Hello S. from Canada and South Africa,

Atypia is NOT a absolute indication for hysterectomy, so no, you don't necessarily need to have your uterus removed. Atypia is not cancer, it is a pre-cancerous finding. It is possible that the only area of atypia was already removed, which then would have solved the problem. A repeat D&C should be done to evaluate the rest of the endometrial tissue. Also you should be cycles for three months then rechecked again by endometrial biopsy or D&C. If there is no abnormality found, then no other testing or treatment needs to be done other than keep you cycling on the birth control pill.

However, if you want you uterus out, and that is understandable, it is certainly a option for you and a vaginal hysterectomy would be fine. Make sure that your doctor keeps the ovaries intact i.e. does not remove them. You still need them to produce adequate hormone that your body needs. It's your choice. Make sure your doctor understands and is told that you want to keep your ovaries. There is absolutely no reason to have them removed.

Thank you for your question all the way from South Aftrica, addressing a problem that many women around the world face as well.

Good luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.

Comment: Thank you Dr. Ramirez! Very timely and useful.

Infertility Workup for Young Woman with Chlamydia and Previous Drug Addiction

Question:

I am 20 years old, married, and have been trying to get pregnant. About 2 1/2 years ago I became very dependant on prescription narcotics because of herniated discs in my back. I was able to get off of the pain medicine and was put on suboxone. I am taking 8mg daily of it. As for trying to conceive, I've never been on birth control pills and we have been "careful" up until 6 months ago. We have been trying to get pregnant for the last 6 months. I am starting to worry that I have some infertility issues. My periods have always been normal, but for the last 3 months they have been lasting about 10 days (when they were 5-7 before) and the first 3 or 4 days I am just barely spotting, but it is brown and really thick. Nothing I have ever experienced before. I have an appointment scheduled this month with a gynecologist, but I am embarrassed to talk to her about these issues.

I also contracted chlamydia about 3 years ago. I am scared that I may have had it for a long period of time. I was treated for it and am okay, but I have read that sometimes if you have it for a long time it can cause scar tissue and make it hard for you to get pregnant. Finally, my last question is, do you think because of the pain medication I could have become infertile? I know I will eventually have to talk to the doctor about these issues. Do you know what kind of tests they could do right off the bat knowing my history?

I think it is wonderful that you offer your time to answer these long questions :) Thank you so much!

Answer:

Thank you for your question. You have several questions and issues within your note. I hope to answer each one, but if I miss any, please let me know.

You are 26 years old and that puts you in the highest fertility years of your life. Statistically, 85% of women in your age group will become pregnant by one year of trying. Anyone exceeding that time frame is considered infertile. Since you have not gotten pregnant in 3 years, it seems that there is some type of problem going on. Part of it could be your addition, but as you know, addicts get pregnant all the time. There are probably some other issues going on. Since you are off the oxycodone, I think the Chlamydia needs to be looked at. The bottom line is that you need to have a complete infertility evaluation. This can be done with a general OB/GYN or a fertility specialist. In order to not waste time, I recommend that you see a fertility specialist (someone that does ALL levels of infertility care and treatments).

Chlamydia is a silent bacteria that can damage the tubes causing blockage. If that happens, you are at risk for a tubal pregnancy (ectopic), or will not get pregnant by natural means. You would need to proceed to IVF (in vitro fertilization) if the tubes are blocked.

The basic infertility workup that I do is as follows:

1. Cycle day #2 or 3 hormone panel to check ovarian, thyroid and pituitary function.

2. Hysterosalpingogram (HSG) to check the tubes.

3. Diagnostic hysteroscopy to check the uterus, ovaries and tubes.

4. Pelvic ultrasound to check the uterus, ovaries and tubes.

5. Endometrial biopsy to check the uterine lining.

6. Semen analysis to check the male.

7. Mid luteal progesterone level to check for ovulation.

8. Laparoscopy (if needed) to check for pelvic abnormalities such as endometriosis and scar tissue.

I know that you were being careful, but the failure rate of being careful is pretty high. Since you were not on birth control pills it is a bit troubling that you have not been able to get pregnant. I think you need to undergo an evaluation. I also think you need to be totally honest and up front with your doctor. He/She needs to be able to see all the circumstances and take them into consideration. At this point, if your doctor tells you to keep trying, I would recommend you see another doctor for a second opinion. Chlamydia blocks tubes by causing scar tissue formation within. It is not surgically repairable. The only way to diagnose this is to do a hysterosalpingogram (HSG).

I hope this helps and good luck!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

www.montereybayivf.com

INFERTILITY EVALUATION ABC'S

I thought I would share my approach to the infertility evaluation. I have seen many patients referred to me, who have not undergone a complete infertility evaluation. Many physicians approach this haphazardly, checking some things but not others. Like other disease states, in order to find the diagnosis, all the different possiblities must be ruled out. In 30% of cases, there is more than one problem, and in 30% of cases it involves both the man and women. Therefore all these systems must be checked. There are basically 9 steps that are required to become pregnant. These steps are a sequence of events, such that, if there is a disturbance in any part of the sequence, then the entire process fails. These steps are 1. Brain sends signals (FSH hormone) to the ovary to begin the ovulation process, and the Ovary begins the maturation of the egg > 2. Ovulation occurs where the egg is expelled from the ovary into the culdesac > 3. The egg has to find the fimbria of the tube. > 4. The egg enters the tube where the sperm needs to be waiting, such that, the sperm needs to have proceeded from the vagina into the cervix, into the uterus then into the tube. > 5. The sperm has to fertilize the egg. > 6. The egg begins developing and dividing and passes through the tube (7-days). > 7. The formed embryo now enters into the uterus. > 8. The embryo has to hatch. > 9. the embryo has to implant into the lining of the uterus. The infertility evaluation that is recommended, checks each one of these steps and I've listed them with the respective step in the sequence:


1. Hormone levels on cycle day # 2 or 3. This is to test to see if the hormone levels, that the brain is producing, are normal at the start of the cycle. This can also give an indication of how the ovary is functioning and able to be stimulated. If the FSH level is elevated, it could indicate that the ovary is already beginning to slow down and/or approaching menopause. If the FSH is elevated, some physicians will proceed with a Clomid challenge test to see if the ovary is past the point where it can be stimulated by fertility medications. The only way to see if the ovary is maturing an egg is to do an ultrasound, in sequence, and see if a growing ovarian follicle is present. This is not usually done as part of the basic infertility evaluation.

2. Mid-luteal progesterone test on cycle day # 20-22. The progesterone level is increased when ovulation occurs, so this in an indirect test of ovulation.

3. Laparoscopy. Any abnormalities in the culdesac, the part of the female pelvis where the egg passes through and where the fimbriated end of the fallopian tubes sit, such as endometriosis or adhesions or tubal abnormalities, can affect the eggs ability to be picked up by the tube. The only test for this is laparoscopy, where a scope is inserted through the belly button to look inside.

4. Hysterosalpingogram. Sperm and egg get together in the fallopian tube. A hysterosalpingogram (HSG) is done to test if the tube is open. This is an x-ray test where a dye is injected into the uterus and passes through the tubes. X-rays are taken in various intervals to confirm that the dye passes into the pelvis.

5. Semen Analysis. We do not have a test to see if fertilization can occur. Therefore, we test the sperm as an indirect method to assess its potential. This is done with a semen analysis. In this analysis we test for the number of sperm, the number of sperm that are swimming (motility)-which is also a measure of the number of live sperm, and the number of normally formed sperm (morphology). This is not just a test of numbers. It is an indirect indication of sperm function. If there is an abnormality then this may indicate that the sperm may not be able to fertilize an egg. The only way to assess if your husband's sperm can fertilize your egg is to remove your eggs and put them together with his sperm, then see what happens. That cannot be done without in vitro fertilization.

6. There is no test for this step, but the HSG indirectly gives evidence that the tube is open and the egg has the potential to pass through.

7. Hysteroscopy. The uterine cavity is tested by a procedure called a hysteroscopy. In this test, a scope is passed through the cervix and the uterine cavity is visualized directly to make sure it is normal. I do this test in my office but most gynecologists do this test in a surgery center.

8. There is no test for this step.

9. An endometrial biopsy is done at the end of the cycle, just before onset of menses, usually cycle day # 26-28. The biopsy tells us if the uterine lining is developed adequately for implantation.

10. Pelvic ultrasound. I do one additional test, which is a pelvic ultrasound. This allows me to assess the uterus, especially the muscle layer and anatomy, the ovaries to rule out cysts and tumors, and if there are any adnexal abnormalities (the areas around the ovaries). Sometimes a dilated tube can be seen.