Endometrial Hyperplasia 

Levator Syndrome

 Healthy Living - Staying Healthy for the Holidays 

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Medical Fact

Endometrial Hyperplasia

Endometrial hyperplasia is simply when the lining of the uterus, or the  endometrium, becomes too thick. It is typically caused by excess estrogen, without progesterone.

During a female menstrual cycle, if ovulation does not occur, progesterone is not made and the lining of the uterus is not shed. This may cause the endometrium to continue to grow from excess estrogen. In some cases, the cells of the lining of the uterus may bunch together and become abnormal. This condition, called hyperplasia, can progress to early cancer of the uterine lining for a small percentage of women. Endometrial hyperplasia is classified as simple or complex - the complex form can develop further.

Typically, this condition occurs during perimenopause, when ovulation does not occur regularly, or after menopause, when ovulation stops and progesterone is not longer produced. Other instances where women may have high levels of estrogen and not enough progesterone include:

• taking high doses of estrogen for a prolonged amount of time after menopause (in women who have not had a hysterectomy) without the protection of corresponding progesterone - currently an uncommon occurrance
• prolonged, irregular menstrual periods, especially connected to infertility
• obesity

Endometrial hyperplasia is more common in women with the following risk factors:

• Older than age 35
• White ethnicity
• Never pregnant
• Experiencing menopause at an older age
• Started menstruation at an early age
• History of diabetes, polycystic ovary syndrome, gallbladder disease or thyroid disease
• Obesity
• Family history of ovarian, colon or uterine cancer 

Oral contraceptive, or "birth control pills" actually reduce the incidence of endometrial hyperplasia. The most common symptom of endometrial hyperplasia is abnormal uterine bleeding. Others include excessive bleeding during your menstrual cycle, menstrual cycles that are shorter than 21 days and any bleeding after menopause.

Endometrial hyperplasia is typically diagnosed by a biopsy of the uterine lining, but may be suspected on ultrasound if a very thick uterine lining is found.

In most cases, this condition can be treated with progesterobe, given orally or as a shot.  

The following steps may be take to reduce your risks and try to prevent endometrial hyperplasia:

 - If you are taking estrogen after menopause, add progestin or progesterone

- If your periods are irregular, you can take a birth control pill to help regulate your menstrual cycle

- If you are overweight, losing weight could help significantly

As always, if you have any concerns or think you might be suffering from endometrial hyperplasia, please make an appointment with one of our doctors.

Pelvic Floor Dysfunction: Levator Syndrome

By Dr. Audrey Romero

Pelvic floor spasm, levator myalgia or myofascial pain syndrome are all terms used to describe a condition that may affect as many as 78% of women  with chronic pelvic pain.

The diagnosis of chronic pelvic pain is frustrating for both the patient and challenging for the physician.  Often vague symptoms including flares in pelvic pain and inconsistent triggering events make it difficult to make a clear diagnosis.

Symptoms may include:

• pelvic pressure and pain
• bladder symptoms such as bladder spasms, frequency, urgency and burning
• complaints of pain with sexual relations
• complaints of rectal discomfort

Patients frequently associate the onset of symptoms with an acute event such as a "bad" urinary tract infection or a history of pelvic or vaginal surgery.  Often, numerous tests and studies are conducted in an attempt to uncover the source of the pain, which commonly turn out negative -leaving patients frustrated and concerned.

In general, all that is necessary to make the diagnosis of levator spasm is a careful pelvic examination done in the physician's office.   The exam is characterized by tight band like pelvic muscles called the levator ani, that, when touched by the physician, reproduces all the patient's pain. The levator ani is a large complex of muscles that line the pelvic girdle and provide support to the vagina, bladder and rectum.

The diagnosis of levator spasm often surprises the patient. While we are all familiar with the term "muscle spasm", the location of this muscle spasm is unexpected. The muscle spasm is the main cause of the patients pain, however, it is important to realize that there was likely some underlying process that triggered the original spasm. In order to provide the most effective treatment of the pain it is important to attempt to identify the underlying cause rather than simply treating the symptoms.

There are numerous therapeutic options for the treatment of levator spasm:

• Muscle relaxants to alleviate pain symptoms.
• Valium - either orally or compounded into vaginal suppositories that work directly on the muscle to aid in relaxation
• Pelvic floor physical therapy
• Trigger-point injections
• A newer, more invasive procedure, called neuromodulation
• Physical therapy -minimally invasive and shown to have moderate to long-term success in treatment of levator spasm. The one drawback of this type of therapy is it requires a highly specialized therapist.  

Trigger points are tender areas within the contracted muscle. The thought process behind trigger point injections is an aim to anesthetize or relax these muscles by injecting the muscle with medications. While the optimal injectable agent is unknown, many practitioners use medications such as lidocaine. There are several research protocols looking at the use of Botulinum toxin A as a possible treatment modality. The thought process behind use of botulinum toxin is it causes paralysis of the contracted muscles and therefore should help in alleviating the pain.

Neuromodulation is the science of using electrical impulses to alter neuronal activities. Neuromodulation has been used extensively in the treatment of overactive bladder. It is not FDA approved for the treatment of chronic pelvic pain however, most of the investigators using it for the treatment of overactive bladder noted improvement in symptoms such as pelvic pain. Neuromodulation is moderately invasive and requires implantation in the operating room. It appears to show promise but requires further study before it can be recommended as treatment for chronic pelvic pain.

The good news for patients is that a simple office examination can help identify levator spasm and, once diagnosed, there are options out there to help alleviate the pain.

Dr. Romero is a board certified sub specialist in urogynecology and trained at Duke University medical school.

It's a common misconception that you need to "prepare" yourself to  over-indulge during the holiday season with the vast number of parties, celebrations and comfort food desired in cold weather. Instead, it tends to be more beneficial if you simply fit the holiday season into your normal, healthy routine and approach it with moderation. Indulge on a few treats, without bingeing and continue on with your normal routine.

Often you will hear people say "I'll go off my diet for the holiday". If you have mastered the balance of eating and exercising as your normal routine - there is no need to ever "diet" again. You simply need to eat when you are hungry, make smart choices and allow yourself a treat once and a while, rather than forbidding yourself- which leads to over-indulgence.

There are some basic rules of thought to keep in mind during the holiday season:

1. Eat four to six smaller meals rather than "saving" yourself for that special holiday meal.  When you are starving, you tend to eat much more.  By eating small meals throughout the day, you will increase your metabolism while thwarting off the holiday binge.

2. Plan a workout before a holiday party or meal. This will allow you to feel good the entire day, increase your metabolism and help resist the urge to over-eat.

3. Slow down when you eat.  It takes at least 20 minutes for our brains to signal we are full - therefore, the slower we eat, the less we consume, the fuller we feel.

4. Take a taste. Sometimes, all it takes is taking a bite of that special dessert. Usually the first bite is the best. After that, it's not as enjoyable and feels worse when you clean your plate.

5. Eat nutritionally dense holiday foods - ie. turkey, vegetables, sweet potatoes, nuts, etc.

6.  Avoid too many "empty" calories by drinking too much alcohol. The more you drink, the lower your inhibitions, the less will power. Enjoy a glass or two, but know your limit.

7. Watch your portions and try to fill your plate with the healthier alternatives.

8. Think about the after-feel. How good you will feel if you maintain a healthy approach to a holiday party vs. the heavy, guilty feeling of over-indulging. The next day, you will be ready to go!

Allow the holidays to fit into your lifestyle rather than "preparing" for them.

This month, we highlight Dr. Jacqueline Saitta.

Jacqueline Saitta, M.D.,  has been with practice for almost four years.   Originally from Wisconsin, she completed her undergraduate work at Beloit College.