What is endometriosis, how does it occur?

Endometriosis is when tissue similar to tissue normally found in the uterus is located outside the uterus. The tissue that lines the inside of the uterus is called ‘endometrium’, and when it is found outside the uterus, it is called ‘endometriosis’.

There are four main theories about the development of endometriosis. The most widely accepted theory is that menstrual blood along with the endometrial tissue travel backwards up the fallopian tubes and spill into the pelvic cavity. Thus, endometriosis develops from endometrial tissues shed in the lower abdominal cavity (pelvis). This theory is called retrograde menstruation. In addition, there are other theories and genetic changes that predispose to the development of endometriosis

Does endometriosis prevent pregnancy?

Endometriosis can make it harder to conceive. The main reason for this is that the ovaries and tubes which are needed for pregnancy can be damaged due to endometriosis. Still, many women with endometriosis can get pregnant on their own. After conception, endometriosis is not harmful to pregnancy. Pregnancy status, on the other hand, relieves complaints related to endometriosis most of the time.

I have a chocolate cyst, should I have surgery?

Some women may develop ovarian cysts that contain endometriosis. These cysts are called endometrioma (chocolate cyst). The reason why the endometriomas are called chocolate cyst is that the cyst is filled with old blood and endometriosis, which looks like liquid chocolate.

We have many treatment options for patients with a prediagnosis of endometriosis. Type of the treatment to be chosen is determined by the criteria such as the patient’s future pregnancy plan, complaints and the possibility of the cyst being a borderline tumor or malignant tumor. Surgery may be a good option for you if:

Tenderness and severe pain in a certain area

Failure to reduce complaints despite drug treatment attempts

the appearance of the mass is suspicious

If there is a problem getting pregnant and the source of this problem is considered endometriosis

You will make the best decision after the examination, together with your doctor’s recommendations.

Deciding the necessity of the surgery for endometriosis and performing the surgery meticulously is very important to protect the ovarian reserve. As the operation method, laparoscopy (keyhole surgery) is always our first choice.

What is HPV? How is it transmitted? Is a condom sufficient to prevent transmission?

Human Papillomavirus (HPV) is a virus that is transmitted by skin contact. It has more than 100 different types. It is usually transmitted by sexual contact. This may be a vaginal intercourse, as well as oral sex, anal sex, or any contact involving the genital area (e.g.: from the hand to the genital area). Sexual transmission may not be the case for 100% of HPV infections. While condoms prevent many sexually transmitted infections, they do not provide complete protection against HPV. The reason for this is that condom does not cover the entire genital area.

Is HPV Only Sexually Transmitted?

HPV is the most common sexually transmitted virus in humans. Non-sexual transmission of HPV has always been the subject of controversy.

Studies on the newly acquired HPV infection showed that HPV enters the body shortly after the first sexual intercourse. In the United States, as a result of a prospective study of women studying at the university and having sexual intercourse for the first time, 40% of these women became HPV positive within the 24 months. HPV 16 was isolated in 10% of HPV (+) cases.

However, we know that HPV can be spread without sexual intercourse as well.

Transmission from external environment

Although it is almost always sexually transmitted, HPV is one of the rare viruses resistant to the environment due to its stable capsid. It can protect its infectious structure on external surfaces. It is even resistant to commonly used disinfectants. The virus is transmitted to external environments through shedding of epithelial cells. In a study that tested the resistance of HPV against dryness in the external environment, HPV was shown to maintain its 50% infectivity at room temperature on the 3rd day. This data reveals the risk of non-sexual transmission of HPV.

A study investigating the exposure of HPV 16 to 11 to commonly used disinfectants has yielded interesting results. HPV has managed to resist the effects of glutaraldehyde, a broad antimicrobial commonly used in hospitals (glutaraldehyde has been shown to be effective against adenovirus, parvovirus, and enteroviruses). Orthophthalaldehyde, which is used as an alternative to glutaraldehyde, has also failed to show full efficacy against HPV 16. HPV also remained resistant to alcohol-based disinfectants such as ethanol and isopropanol. HPV has finally been found susceptible to hypochlorite and peracetic acid. Here is one of the points that should be considered: Hand disinfectant systems do not effectively prevent transmission of HPV.

Nosocomial (hospital-acquired) spread is quite common for many virus infections. In the hospital-acquired transmission of HPV, the potential route is transvaginal ultrasound probes. HPV-containing vaginal probes are candidates for transmission, as they will be in contact with the cervix and vagina during the examination. In the studies that examined HPV DNA on probes, the existence of not only HPV DNA but also free virions has been shown. Although the probes are cleaned between patients, extensive sterilization is not often performed, especially considering the delicate structure of the instrument. A sheath (condom, gloves,…) is placed on the probe for each patient during the examination. However, the perforation chance of these sheaths is up to 9%.

In a study conducted on instruments used in the gynecology outpatient clinic, HPV and its types were investigated in the morning and evening of the same day. These instruments and objects included examination table, colposcope, examination lamp, toilet seat and siphon. HPV was not detected in any of these instruments at 08:30 in the morning, while it was detected in all at 16:30 in the afternoon. HPV 6 and 16 were the most commonly detected types.

Oral cavity is also a site that can be infected with HPV and transmit HPV. Just as microtraumas, including sexual intercourse, are required for HPV to enter the cervical epithelium, many activities take place in the oral cavity that can create microtraumas such as dental care and eating.

Auto-inoculation

Another way of non-sexual transmission of HPV is auto-inoculation. Data on this comes from studies on women and children who have stated that they have not had sexual contact before. In a study that looked at the HPV positivity of women with and without sexual intercourse, HPV was detected in 51% of patients in the first group and 69% of patients in the second group. In other words, half of the women who stated that they did not have sexual intercourse were exposed to HPV. In a study conducted in children, low risk HPV types were found. HPV DNA has been detected especially in the fingers of people infected with HPV. Therefore, it is possible for these people to infect HPV with their hands and to people around them with non-sexual physical contact.

Vertical transmission

Vertical transmission from mother to baby is one of the other possible ways of transmission. This potential transmission can occur either inside the womb or during childbirth or postpartum contact. The transition from the birth canal of the mother with HPV to the baby has been demonstrated. In fact, the higher the HPV DNA load in the mother, the higher the chance of passing HPV to the infant. According to the results of the studies of genome sequences and HPV typing, the mother is directly responsible for infectious transmission. In HPV (+) pregnant women, HPV DNA has been shown in both placenta and amniotic fluid. Although this suggests the possibility of congenital infection, the highest risk of transmission to the baby occurs in birth canal during childbirth. Many times, HPV DNA is found in the oral cavity of the newborn. We know that HPV is associated with oral cancers, but the regression of HPV transmitted to newborns is over 90% in 1-2 months and 100% in 6 months. However, low-risk types such as HPV 6 and -11 can lead to juvenile recurrent respiratory papillomatosis. It usually occurs between the ages of 2-5. The probability of developing condyloma in the children of women with condyloma is 200 times more than the children of women without condyloma.

How often does it occur?

Many of the men and women are exposed to HPV for the first time between tha age of 15 and 25. It has been estimated that 75 to 80 percent of sexually active adults will get at least one genital HPV infection before the age of 50.

How do I know if I have HPV?

Many people infected with HPV do not have any signs or symptoms. Again, for a large part of these people, there will be no problem related to HPV. However, HPV infection may not regress in 10-20% of the people who are infected. In this case, there is the possibility of developing lesions due to HPV, especially cervical precancerous lesions and cervical cancer. Although many of the patients presenting with HPV infection have cancer concerns, it should not be forgotten that the development of cervical cancer takes an average of 20-25 years after the new HPV infection. Therefore, the diagnosis and treatment of lesions that will occur before the development of cancer can be easily provided in patients who have regular cervical cancer screening (HPV test and/or smear test). What we say to our patients who have an abnormality in the smear or HPV test is that they ‘should not worry and they are very unlikely to develop cancer as long as they attend the procedures and follow-ups we recommend’.

Can I get an HPV vaccine?

There are three different HPV vaccines available worldwide: Bivalent vaccine (protects against HPV 16 and 18); quadrivalent vaccine (protects against HPV 6, 11, 16 and 18); and nine valent vaccine (protects against HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58).

It is appropriate to vaccinate individuals under the age of 15, who do not have any immunosuppressive disease, at least 6 months apart, twice in total.

If you are 15 or older, you must have three injections. The second injection is administered 1-2 months after the first injection; the third injection is made 6 months after the first.

If you have a disease that suppresses your immune system, you must be vaccinated three times, regardless of your age.

The vaccine may not be suitable for everyone. In some rare cases (allergy, pregnancy, etc.), it would be appropriate to talk to your doctor for detailed information. Do not forget that your doctor will always give the best information about your medical problems and questions during an office visit.

Who should be vaccinated?

In many developed countries, children are enrolled in the HPV vaccination program from the age of 9. People who are not vaccinated are also given the vaccine until the age of 26. The FDA has approved the use of HPV vaccine until age 45.

People who will see the best benefit from the HPV vaccine will be those who have been vaccinated before being sexually active and thus have been protected from exposure to HPV. The vaccine will not contribute to the virus clearance of anyone with HPV infection or to regression of the lesion in patients with cervical lesions. However, even if you were previously sexually active, and developed genital warts, had an abnormal HPV test and/or smear, and even had been treated for pre-cervical cancer lesions (e.g.: conization (LEEP)), you may benefit from HPV vaccine to some extent.

Get your kids vaccinated because it works best if the vaccine is done before they become sexually active.

How effective is the HPV vaccine?

HPV vaccine is HIGHLY EFFECTIVE in preventing HPV infections and related diseases. As we mentioned above, the effectiveness of the vaccine may vary depending on the individual (age, sexual activity, immune system etc.).

The vaccine prevents genital warts (condyloma). It prevents the spread of virus to sexual partner. It prevents not only cervical cancer, but also HPV-related anal cancer, mouth and throat cancers.

How long does the vaccine protection last?

HPV vaccine has been available since 2006 Concerning this relatively new vaccine, there is not yet sufficient scientific data on how long it is effective for and the need for re-vaccination in the future. In short-term studies, the efficacy of HPV vaccine has not been shown to decrease over time.

I got vaccinated, should I still have cervical cancer screening?

Yes. Having an HPV vaccine will not change the frequency of your cervical cancer screening.  Remember, there are more than 100 different types of HPV and HPV vaccine does not cover all HPV types. Still, you can feel more comfortable when going for a test.

What are the side effects of HPV vaccine?

Side effects of HPV vaccine are not different from other vaccines. The most common side effect is slight redness and tenderness at the injection site.

Although vaccination during pregnancy does not have any negative effects on the fetus, it is not recommended to administer the vaccine during pregnancy.

How is cervical cancer screening done?

We have two tests for scanning: Smear test and HPV test. Both are based on the examination of the swab taken from the cervix during the gynecological examination. While both can be done together, single test can be performed in some people. According to the national screening program of our country, women over the age of 30 are tested HPV every 5 years.

My Smear or HPV test was positive. What should I do?

Do not worry! After all, this is a screening test. As with any screening test, although there are no diseases or suspicious conditions, there will always be people who have a false positive test result. However, there are variants of abnormalities for both tests. All you have to do is contact a gynecologist. Some patients with abnormal screening will not require further diagnosis and treatment. In some cases, colposcopy (examination of the cervix and vagina with a microscope) and biopsy may be required according to the findings. You will make this decision with your physician. None of them should cause any concern or fear.

What is colposcopy? How is it done?

Colposcope is a microscope that gives the opportunity to examine and magnify the image of cervix (neck of the uterus), vagina, vulva and anus up to 40 times. Colposcopy takes 5-10 minutes on average. It is not much different from routine gynecological examination. It is aimed to see abnormal areas during the procedure. For this purpose, acetic acid is applied to the cervix. You may feel this as a slight burning. A biopsy can be performed, if necessary. In most cases, it does not require local anesthesia. A biopsy can lead to mild contraction but will not cause a severe pain. A biopsy should not make you worry. This does not mean that you have a pre-cancerous lesion. The tissue sample will be send to the pathology lab and will be examined by the pathologist.

We can perform colposcopy during the days after the menstruation ends. If you are using blood thinner medications, you must inform your doctor about it.

Your doctor will inform you about the situations that you should pay attention to after colposcopy.

I have genital warts. Why did it occur? How did I get it? Will it recover? Does it repeat? Will I get cancer?

As I mentioned above, there are over 100 HPV types. These include some types that can lead to cancer (mostly type 16 and type 18); however, most warts occur as a result of type 6 and type 11. Cancer development due to type 6 and type 11 is not expected.

Genital warts also occur with direct skin contact. Almost all of these occur through sexual intercourse.

Treating warts does not prevent transmission of HPV. Most people with HPV also do not develop warts.

Warts can develop weeks or even months after exposure to HPV. So when and how you are infected is often unknown.

We have many treatment alternatives according to the type, location, spread and characteristics of the genital warts. In addition to our high success rates in treatment, all of them have some risk of recurrence. It is appropriate to discuss the details with your doctor after the examination.

I’ve entered menopause. I have had spotting. What should I do?

There are many reasons that cause vaginal bleeding in menopause. Bleeding resembling a menstrual period can be seen in women who take hormone therapy. Apart from this, bleeding in menopause is considered abnormal. In this case, you should definitely contact your doctor.

The main causes of bleeding in menopause are:

Atrophy (tissue thinning in intrauterine tissue and vagina due to low hormone level compared to pre-menopause)

Pre-cancerous conditions (atypical hyperplasia) or uterine cancer in the intrauterine tissue

Polyp, myoma (fibroids)

Infection

Use of blood thinners

What is a fibroid? How is it formed?

Uterine fibroids (Myomas) are noncancerous growths of the uterus. They are benign tumors. A large part of the uterus consists of muscle. Fibroids (myomas) also originate from the muscle. They can grow on the inner or outer wall of the womb. Fibroids can fill the entire uterus. They usually exist in multiple numbers. Fibroids are benign tumors and their chance of turning into cancer is very low.

It remains unclear exactly what causes fibroids. They respond to estrogen and progesterone hormones. In addition, some women have special genes that tend to develop fibroids. About 80% of women have or will develop fibroids in their lifetime.

How do I know if I have fibroids?

Fibroids can be microscopic or have size of a grapefruit and even larger. Most of them are small and do not cause any complains. Nevertheless, some fibroids (depending on their size and location) can lead to menstrual cycle disruption, excessive bleeding, pressure sensation, pain, or frequent urination.

Besides, we recommend that every woman have an annual gynecological examination. In these examinations, the presence of uterine fibroids can be detected.

Do fibroids prevent getting pregnant? Does it increase the chance of miscarriage if I become pregnant?

Many women with fibroids can conceive without any problems. Some types of fibroids that disrupt the inner wall of the uterus can be problematic for women trying to conceive. Fibroids, which are on the outer wall of the uterus and do not cause any disruption on the inner wall, have a little impact on fertility.

As I mentioned before, many women with fibroids will have a completely normal pregnancy and will take their baby home without any problem. In a small group of patients (with large fibroids and those with fibroids located at risky sites), however, fibroids can cause some problems, such as miscarriage or preterm birth.

Should I have surgery for fibroids?

Depending on your age, complaints, location of fibroid, size and appearance, your doctor may recommend surgery. In our daily practice, we can recommend surgery to patients with fibroid-related vaginal bleeding, pain, and pressure sensation (if these complaints do not improve with drug treatments), patients who plan pregnancy and when we suspect a malignant tumor during the examination.

It is worth noting: After your fibroids are removed, the probability of recurrence is 10% until you enter menopause. Therefore, consult your physician about whether fibroid surgery is required.

Which surgery is best for fibroids: open surgery or keyhole surgery?

If the need for surgery has arisen and you have decided on having an operation, you can discuss the type of surgery (open vs. keyhole) with your doctor. The first rule is this: The method the physician feels comfortable should be preferred.

Of course, keyhole surgery (laparoscopy, robotic surgery) has many advantages (early recovery, early discharge from hospital, smaller incision, aesthetic advantage etc.) compared to open surgery. In our practice, we recommend keyhole surgery to all patients who are suitable for this procedure.

An ovarian cyst was found during my pelvic exam. Could my irregular periods be related to this?

Ovarian cysts are fluid-filled sacs in the ovary. They can be seen in women of almost any age. Ovarian cysts can be of various sizes (2 cm – 40 cm). While they can cause complaints such as pressure or pain in some women, many others do not have any symptoms. Irregular menstrual periods are not due to ovarian cysts, except in rare cases.

Do I need to have surgery for my ovarian cyst? Is a tissue sample submitted to the pathology lab during surgery?

Ovarian cysts do not always require treatment. Based on the patient’s age, symptoms, physical exam and some blood results, a follow-up or treatment decision is made. In the following cases, we can recommend surgery for ovarian cyst:

Persistent pain-pressure sensation, possibility of rupture in the cyst (bursting of the cyst)

Large size of the cyst and low probability of spontaneous regression

Cancer suspicion

If the cyst does not regress during follow-ups and some changes are detected on the ultrasound

In very rare cases, we ask for MRI or CT scan for further investigation. Pelvic examination and ultrasound will be sufficient for us on how to manage the cyst (follow-up or treatment). In patients we recommend surgery, we advise laparoscopy (keyhole surgery) as the first option whenever possible. When we perform an operation (open or keyhole surgery) for a cyst with cancer suspicion, the cyst is removed during surgery and sent to pathology to be examined at that moment. This is called frozen section. In about 20-30 minutes, after the examination of the pathologist, the operation is carried out according to the result.

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