Hello everyone. I am Aiman Nissar Mahajan, a pharmacy student from Delhi Pharmaceutical Sciences and Research University (DPSRU). I’m doing my M. Pharm and am also a volunteer in the multimedia team for Aura E-Magazine.

Today we are here in conversation with Dr. Beena Abdul. Dr. Beena is a consultant gynaecologist and surgeon. She’s currently working at Oxford University Hospital and she has a special interest in ovarian debulking surgery and laparoscopic hysterectomy in high BMI ladies. She is also involved in the screening of cervical and vulvar cancers in the UK. She is a board member of Target Ovarian Cancer and is also involved in teaching general practitioners.

ANM: When should young girls go see a gynaecologist for the first time? Is it when we start menstruating or is it when we are trying to get pregnant or are pregnant? And how often should we go see a gynaecologist?

BA – First of all, let me thank you for inviting me to this session. There is no particular or fixed time. However, having said that, I would like to highlight some concerns. As females, there are so many types of problems that can be diagnosed, especially cancer, when you go for screening. One of the most common cancers in India is cervical cancer, which is 100% screenable, and 100% treatable if diagnosed early. Once women are in the reproductive age group, they have to go for screening once every three years. I think that’s what we practice all over the world, but I think it’s a developing practice in India. We should increase the awareness among women around this. Another thing I would like to mention is that when ladies notice abnormal swelling in their abdomen, or when they get some problems in passing urine or in opening their bowels or severe pain associated with their periods – these are general indications that a woman should consult a gynaecologist rather than ignore it as one of the “female things.”

ANM: Talking about menstruation, you’re seeing irregularities in menstruation. How normal is it? Because irregularities in menstruation are associated with a lot of disorders that are related to a woman’s health, like PCOD.

BA – The menstrual irregularities are usually seen when girls are attaining menarche and at the time of menopause. Most of the times, the reason why they don’t get regular periods is that they’re not ovulating correctly. So what happens is that either they have very heavy periods or they don’t have periods for about two or three months at a time. They are not ovulating because, in young girls, the ovaries are not very developed, so they are not having regular periods. In young adults, the most common indication is PCOS – Polycystic Ovary Disease where several eggs are forming but they don’t mature and they don’t release the egg. That is something that I would like to discuss in detail because it is very important that we identify it and we get treatment for it. PCOS is not just a disease affecting the ovary, it affects the whole body. It’s like a syndrome, it affects different systems. PCOS is a vicious cycle. Those women who have high weight, high BMI or insulin resistance, are more prone to get diabetes, have other metabolic disorders, and sometimes have increased cholesterol levels in their body. There are two hormones which are produced in our body, the most important ones are estrogen and progesterone. When they don’t ovulate, they don’t produce the hormone progesterone. So what happens is that the lining of the womb is continuously exposed to estrogen. So, when it is continuously exposed to estrogen, the lining of the womb becomes thicker and thicker and thicker and starts shedding. That’s why they don’t get periods for three or four months and then they start shedding and they get very heavy periods and it’s sometimes uncontrollable. So, there is a high risk of having endometrial cancer, which means cancer in the lining of the womb, which is otherwise called uterine cancer. When you don’t get a regular period, then you need to get it checked and then seek treatment. I would say it’s simple as far as we doctors are concerned but it’s difficult from the patient’s point of view. The most important thing is to have discipline in life, in the sense, that you need to control your weight and also you have to have a regular exercise pattern which actually changes your insulin resistance and then your periods tend to come back to normal. Sometimes if it happens in young ladies in their late or early 20s, then taking progesterone for about 6 months or a year will bring the cycle back to normal. One important reason for not getting pregnant is also thought to be Polycystic Ovary Disease.

ANM: Some women have menstrual cramps in the early days of their periods and there are a significant number of women who also experience fever and chills. Is that normal to experience during periods?

BA – Yes, different women have different ways of responding to their periods. For some women, they don’t experience anything at all. For some, it is associated with severe abdomen pain and vomiting. Sometimes they have exaggerated physiological responses. Having said that, there are times when ladies get pain before the periods, say for example, a week before the periods and then the pain continues to go through the periods and they find it very difficult to pass urine or loosen their bowel during the period, or it so happens that ladies find it very difficult when they have a sexual relationship and have heavy periods. This should raise the suspicion of whether there is any other reason behind it – such as endometriosis.

Endometriosis is essentially that how we have a lining inside the womb, a similar lining comes to lie outside the womb. So, when you menstruate these tissues outside the womb also start menstruating. So, the blood will collect outside and then cause irritation and periods. That is why you’re getting all these sorts of pain-like conditions. So the question that you asked, sometimes you have irregular periods, that’s quite normal. But this severe sort of pain which affects the quality of life, you should not take that as normal. You need to get investigated.

ANM: So like you said, there is a rise in the number of women who are suffering from PCOD and that is particularly because of the lifestyle change that we have seen over the past few years.

BA – I would say that obesity is one of the main reasons for having PCOD. There are other reasons as well but they are less contributing factors. But among obese women, PCOS is high and hyperinsulinism and insulin resistance is also associated with BMI. So, I think it’s a lifestyle change which is increasing the risk of PCODs.

ANM: Right, so how can we prevent it, for women who haven’t acquired PCOS yet, what changes can they bring in their lifestyle to prevent from getting PCOS?
BA – I wouldn’t say that you can completely prevent PCOS or PCOD from happening, but you can keep it fairly under control if at all you have a tendency to develop PCOS. Sensible eating is what I would advise. The second thing is regular exercise. Regular exercise not only helps you with your PCOS, but it also helps everything in your body. When the metabolism gets up and running and going in the right direction then the PCOS will also be under control. I would say it’s not an isolated problem that is just happening to the ovary. The ovary is just one of the manifestations and how do you know if it is PCOS – this is a very important thing. It’s not that every irregular period is PCOS, not always. Not all obese women get PCOS and PCOS doesn’t happen only in obese people. For some, they develop excess hair growth in their body, some develop facial hair, they develop hair around the abdomen, around the breasts and the upper part of the thigh and legs and the back, which we call hirsutism. It’s very upsetting for young girls and of course the irregular periods and together with these symptoms, then it’s an indication that you should see a gynaecologist and get it checked. Unless you try and control your hormone levels, it also produces excessive androgens. Some of the androgens are also produced from the ovary, so when the egg is not released, it becomes the condition called hyperandrogenism which causes excessive androgens to be produced. These androgens are the main hormones that cause hirsutism and once the hair comes it doesn’t go away easily. You need to undergo cosmetic things, so it’s better to avoid hair growth like that and see a gynaecologist instead.

ANM: Okay, during periods, there was a time when people didn’t even have pads. But now we have options like pads, we have tampons and menstrual cups. So, can you explain to our readers, which of the three is medically safe and also efficient and convenient for them?

Answer – That’s a good question. It’s an individual choice. But I can tell you the pros and cons of each and everything and it’s entirely up to you to use what you want. It’s about comfort. But let me talk about the menstrual cups first because everybody knows what is a pad, what is a tampon. After all, some form of pads have been in the market since periods have started, tampons have been there for the last 25 years, the menstrual cups have only been there for the last ten years, I would say but in India, I think its use has increased in the last 2 years. The good thing about the menstrual cup is that it’s very environment friendly and has less risk of infection. Once you get the hang of it, it’s very easy to use and very economical because once you buy a cup, there are cups you can use for ten years or cups you can use on yearly basis also. So you’re not spending too much money on the pads. I’m sure all of you have experienced the excessive smell that comes from blood when it’s collected outside the body especially when you work in an office or if you’re a surgeon, you have to operate for a long time. Me being a surgeon, I know what it is like and just after a couple of hours it starts producing some odour but when the blood collects inside the body, it’s in the vagina and it doesn’t produce that smell.
The cup is available in different sizes, usually, in the market, there is small, medium and large size. How do you choose which cup is right for you? For example, if you’re not sexually active at all, you can use a small cup, but if you’re worried, that’s fine, you can use a pad. It’s up to you. But if you’re sexually active and it’s very easy, it’s a very soft cup you introduce with fingers and you put inside the vagina, once you put it inside, it opens like an umbrella and collects blood. You can use a cup for about 12 hours but for tampons, you have to take out tampons after 4 to 6 hours. You’re not allowed to leave a tampon inside for 12 hours because it can cause infection. In a menstrual cup, the chances of getting an infection are also less but what you need to be careful about the cup is, because you are inserting it inside the vagina you need to be very careful with washing your hands before, more importantly, then after of course and once you finish using them, in between your periods you just have to wash with normal water, you don’t have to sterilise or anything. Once you finish with periods, you just put it in boiling water for five minutes and then put it in the box and keep it safe. Once you start using it you just boil it, sterilise normally and then you use it.
So, as I said, in a tampon, sometimes you can get life-threatening infections like Toxic Shock Syndrome. The drawback of the pad, everybody knows it’s a foreign body, is an increased risk of having fungal infection because it’s wet outside all the time but you do get pads that don’t get wet. But nowadays there are scented pads which can cause allergic reactions. These are the pros and cons but at the end of the day, women can decide what exactly they want to use. If you ask me as a gynaecologist, I would say my choice would be between pads and cups, certainly not tampons, because they can cause life-threatening infections especially if forgotten inside.

ANM: Thank you for sharing light on this because there are a lot of women out there who want to try menstrual cups. They are a bit hesitant about trying because it’s something that they haven’t used before. So, coming over to the next question, there are women who are unable to conceive and since we’re living in such a medically advanced era, there are multiple options available for them as well. So, can you also explain to our readers what options are available and which of these options are safe?

BA – Well, when it comes to being unable to conceive, you should always think that there is a male factor and there is a female factor. Investigating males is very quick and easy. As you all know, all you have to do is submit semen for analysis to see if there are adequate numbers of sperms or good quality sperms. I think sadly in Indian society, I would say that this is something that’s not done at the very beginning. They always tend to investigate females first. Female investigations are all invasive which means you have to go into the body, even a blood test is also invasive. The second most common reason for infertility is the male reason. It’s not always females. The investigation starts with a simple test to see what the hormone levels are: Follicle Stimulating Hormone, and Luteinising Hormone, which also will help you find out whether you’ve got PCOS or something else. If you take the ovary then you know that PCOS is one of the main reasons. Endometriosis is the lining of the womb that can come to lie outside that can also cause infertility. In such cases, you will know through a laparoscopic examination where the problem lies. The next cause is the tubal cause where the tube is not functioning because, the fertilization, the meeting of the egg and sperm happens in the tube and then from the tube they slowly come into the uterus, and the fertilized egg settles in there. So if there’s any problem with the tube, it doesn’t happen. So why does the problem happen with the tube? One is infection, sexually transmitted infection or even normal pelvic infections or sometimes endometriosis. Now coming to the uterus, the indications, once you know the indication then you know how to investigate. So, what they do is, put in a camera to see as well as inject a dye through the cervix from down below. So what they’re doing is that they inject in the cervix and they close them out of the womb and they inspect the dye. You can see the dye going through the tube and they come out, which means that the pathway is clear, if it doesn’t come out, then you know that there is an obstruction in the pathway somewhere be it in the uterus, could be in the cervix but usually, it’s in the tube. So once you do that, then you know that there is no cause of obstruction anywhere there.

For some ladies, they can’t find any cause, but they just don’t get pregnant. The ladies do find it very difficult to accept the fact that they are not able to get pregnant. There sometimes can be autoantibodies which means that our own body will produce certain cells which don’t like either the egg or the sperm. In that case, we go for IVF pregnancy. Most of these treatments in their newer forms are safer than before. Many reasons behind lack of pregnancy can be there, one of which is anxiety, which means that you’re not getting pregnant in six months or one year. Then you feel more anxious about why this is happening. The more anxious you get, the more unlikely you are to get pregnant. And for them, we advise them to just take it easy, every two to three days have regular intercourse.
The other thing is that it is PCOS. PCOS can be corrected by simple medication. And most of them get pregnant with that. As I told you, some don’t get pregnant with any of this. So, we do give injections to them that can sometimes be risky because they get hyperstimulated, which we call ovarian hyperstimulation syndrome, which means the ovary produces a lot of eggs. Sometimes they develop clots in the legs that could be life-threatening. So, when they do develop these types of symptoms, they should seek medical advice. But the centres that do the treatment, make the ladies well aware. Mostly they are safe 99% of the time, 1% can be life-threatening and I would say 30%, will have some form of side effects like nausea.

ANM: Okay, coming over to the topic, that is your speciality, cancers. What type of cancers are most prevalent in women and how do they originate?

BA – Cancer that is more prevalent in women is breast cancer and the other is cervical cancer, which is on the decrease. And uterine cancer is increasing purely because obesity is increasing in India.. The next cancer is the other cancers which include Vulva and Vagina, which is very rare. Why does this happen? There are two reasons, I would say. One is familial. We have a gene which causes cancer, for example, breast cancer and endometrial cancer or ovarian cancer. They’re associated with certain genes, one of the most common genes that we are familiar with or everybody has heard about is BRCA1 and BRCA2. I’m not sure if you have heard about Angelina Jolie. She created a big wave to create awareness of this gene when she had a bilateral mastectomy. If you have a family history of either two of your first-degree relatives or your siblings having either endometrial cancer or ovarian cancer, these are all linked with the same gene, or breast cancer, I would say it is advisable to go and see a gynaecologist or genetic counsellor to see whether you do have a gene. This is important because if you know that you are carrying a gene then there are ways to find whether you do develop cancer or not. For example, breast cancer. With this gene, there is a 60-80% chance of having breast cancer so many ladies will be subjected to a simple test called a mammogram. It is nothing but an x-ray of the breast where you look at whether they have any early signs of cancer. The next one is ovarian cancer. And once you finish your family life, once you have your kids then we always offer the option of removing the ovary. It’s a very simple operation and we support your hormones from the outside, it is better because the chances of having cancer from the ovary are about 40%, which is very high. Where your inherent ability prevalence of having ovary cancer is only 3% but that is increasing up to 30%-40% and for breast cancer, it is going up to 80%. That is a very high chance of getting cancer. That’s what is called familial or gene-related cancer. And the other is sporadic which means it just happens, none of those reasons. I think as you say, prevention is better than cure with cancers. One of them is cervical cancer, the leading cause of death for females. The reason why cervical cancer patient dies is they don’t produce many symptoms because you can diagnose cervical cancer as a precancerous condition. Do they have symptoms? Not really. You just have to subject yourself to an examination. It’s just a smear. It’s just like a brush. They do a smear. They look at the microscope and see they have precancerous cells that can be treated or even you can have a hysterectomy and that’s done, you’re cured. So you don’t allow them to develop into cancers. There are few warning signs, like spotting after having intercourse, mostly because the cervix has got growth and then when you have sex you tend to bleed slightly, maybe a brown discharge may be a day later you get some red spot because it bleeds very little, but it does not bleed straight away. So, these are the only warning signs you get. Cervical cancer can spread very easily to your bladder, to the ureter and back to your back passage. So what happens is that your kidney gets obstructed, then the ureter is obstructed, that’s when the pain starts, and it is too late to get treated. Cervical cancers, if you can diagnose them, you can prevent them and early cervical cancer is curable. Once it is advanced I think the chances of survival are very less. There are treatment options available.
So the next one is endometrial cancer. Again. Two reasons. One is familial. I also spoke about this, which is gene-related and other one is obesity. When you’re obese, even your fat produces oestrogen. Estrogen is carcinogenic if it is produced in large amounts because the lining of the womb is continuously subjected to estrogen. The lining becomes thicker and thicker and thicker and they change the pattern of the cells therefore the pre-cancerous condition of endometrium. Usually, cervical cancer happens at a very young age, in sexually active in the 30s, and 40s but endometrial cancer usually happens in the late, sixties, seventies and eighties. The reason is it does not happen overnight, it happens over years. Maybe you have heavy bleeding for months and months and months, then they investigate whether they do have cancer or not, which is uterine cancer. So we say that when you see a patient coming to you with bleeding, heavy periods, obesity, hypertension and post-menopause if you see a patient like this, the chances of them having cancer are high. You can predict that there is a chance of having cancer. Ovarian cancer cannot be prevented, to be honest, and you don’t get any symptoms; in a very early stage, all you get is bloating. Sometimes you get an increased frequency of passing urine and abdominal pain. Chances of survival even in developed countries are less than 40-50% despite all the treatment options that are available but endometrial cancer and cervical cancer are preventable. The other important one that I didn’t talk about is breast cancer. Can you prevent it completely? Not really. Can you diagnose it early? Yes. Is it curable? Yes. So, early diagnosed breast cancer is 100% curable. But they don’t produce many symptoms, so women do not seek help until it causes problems. What is the problem they get? Pain, and when they have pain, it is a sign of advanced cancer. Pain happens when it has infiltrated into the nerves, when it goes into the nerves, then it is advanced. I would advise all the ladies to self-examine their breasts for lumps. How do you check your breasts? You should have your mirror, a long mirror so self-examine is very important, we need to give some time for ourselves, every month you just stand in front of the mirror and see if there is a change in the colour or if there is any change in the shape that’s not normal or puckering or if there is an orange peel appearance of the skin, these are early signs of having breast cancer. Also, examine the breast from your underarms with the palm of your hand and see if you can feel any lump or anything other unusual feelings. You can do a regular check-up by yourself if this is not normal. Of course, you can go for an annual check-up but what if this lump happened 2 months after you had your annual check-up, you end up thinking that you’ve already seen a doctor and she said everything’s fine but this happened months later and you’re sitting, waiting to see a gynaecologist after another year.

ANM: About preventable cancers you talked about obesity and diet that can help us prevent getting some types of cancers. Exercises are one thing that we can include in our lifestyle, what changes can we bring in our diet?

BA– We live in a Fast Food World and fast food has created more problems with colon cancer, they are carcinogenic but how is it affecting gynaecological cancer? Fast foods are rich in fat or oil so you tend to develop more fat. You become more obese and obesity is what is causing the problem. I will not tell you what exactly you should eat, you should have a balanced diet, it is better to have a good balance between protein and carbohydrates is what I would advise. In every fast food, how much fat content is there, take a look at it, it takes one minute to see how much fat is in there, and how much protein is there. A high protein diet is better than a high carbohydrate diet.

ANM: Coming over to the last question for our interview which is about vaginal hygiene. There are women who, because of the awkwardness that comes with it, don’t ask about these things, so what is vaginal hygiene? Is it even important to maintain it?

BA – There is nothing like vaginal hygiene because the vagina is the place inside the body if you don’t disturb it, it’s hygienic enough, if you disturb it, that’s when you lose hygiene. We were talking about the menstrual cup, will it affect the vaginal hygiene? Because there is a slight concern since you are inserting something foreign into your body but when you compare the pros and cons of a pad to a vaginal cup the risk of infection is more with the pad than with the cup. That is why I said cups are more welcomed nowadays and I do advise my patients that if they have more risk of having fungal infection outside and all sorts of things that can go into the vagina, use cups. What I would generally advise is to use warm water to wash. Normally, there is an odour in our body, there is also an odour for the secretions in the vagina. The vagina is made in such a way that it is naturally self-cleaning. The normal secretions in the body and the bacteria which is helpful in the vagina will cleanse that area and the secretion will come out, this secretion will have some normal odour, which we have to accept but if that changes in the colour like greenish, yellowish, or if it is a fishy smell, you have to identify yourself. If it is the same odour every time, you don’t have to do anything. Don’t use excessive soap because it’s not good for your body because there are other problems you can get like dryness and if it is itchy, don’t scratch it because again that tends to make the infection go up into the vagina, then it is very difficult to treat things. Use cotton underwear and don’t wear tight underwear, it’s not good for vaginal health. Anything that causes the sweat to stay there can cause infection.
ANM: Thank you very much for the answers.