Q. Can the lower abdomen pain be due to ovulation?
Hello doctor,
For the past two days, I am feeling a mild pain on my lower abdomen and having a feeling that my bowels are not getting cleared. I had my last period about two months back. My periods have become irregular since then. Last month, I got examined and was detected having a uterine fibroid. Can the above pain be due to ovulation?
Hi,
Welcome to icliniq.com.
The best way to check for an ovulation pain is to check for LH (luteinizing hormone) surge with an ovulation kit. If the test is positive, then you are likely to ovulate or have ovulated already. The pain can also be due to submucosal fibroid. I suggest you use tablet Meftal Spas 500 mg (combination of Dicycloverine and Mefenamic acid) twice a day for pain relief. Consult your specialized doctor, discuss with him or her, and take medicine with consent. Hot fomentation to the lower abdomen and lower back can be helpful as well.
Thank you doctor,
My last period was about two months ago. Two days after my periods stopped, I observed few blood clots and so I took Pause and the bleeding stopped. After that, I have not got any bleeding or spotting till date. About a month back, I observed some yellowish white mucus from the vagina, which was sometimes thick and sometimes light with very mild cramping and that has stopped now. Even though I could not check with I-sure kit, I think I started ovulating three weeks back. I took Duphaston for 10 days in the last month. From the past two weeks, I feel a mild cramping in the lower abdomen, only in the morning and I also feel that my bowels are not getting cleared.
Sometimes, I have to go to restroom two times whereas my usual need used to be once per day. I feel discomfort only in the morning and as the day progresses, the discomfort disappears. Since last two days, I am noticing small white and red particles through the vagina along with the yellowish mucus. Can you suggest the reason behind this? I am on a simple and light diet for past two months. I use to have yogurt, muesli and apple for breakfast and have carrot juice one hour after that. I take fruit and vegetable salad in the noon time with yogurt. I have soup and puffed rice in the evening or two pieces of bread with low-fat cheese. I usually have little white rice with fish in the night. I drink about four liters of water in between and sometimes, I do have low sugar biscuits. My next appointment with the doctor is after three days and I will follow you up for better guidance as I am in need of it.
Hi,
Welcome back to icliniq.com.
The fact that you have completed the 10 day course of Duphaston (Dydrogesterone) and hence, you are in a phase of initiating a withdrawal bleed in the next three to five days. The abdominal cramps, constipation, even mild spotting and increased mucoid vaginal discharge are part of a premenstrual syndrome and shall all subside once your withdrawal bleed is initiated. So, I suggest you wait for a few days patiently to allow menses to restart. I can see that you are continuing a very healthy and balanced diet and wish to see your weight and insulin resistance to reduce with the same. Continue the same.
Thank you doctor,
In response to the earlier query, can you please explain the withdrawal bleeding. What is the difference between this and the normal period? My bleeding started three days after stopping Duphaston and I am having periods like cramping. When shall my periods become normal?
Hi,
Welcome back to icliniq.com.
The difference between withdrawal bleeding and natural menses is just that one is induced in response to medication or progesterone and the other is initiated naturally. Once the Duphaston is stopped, the bleeding was induced. The natural menses are initiated once the natural progesterone levels fall down in the body during the secretory phase. So, in short, both cause bleeding. But, one is induced and the other is natural. As you have started your withdrawal bleed now, as expected, the menses are likely to be accompanied with pain and cramps in light of the submucosal fibroid. I am sure your gynecologist would have planned a diagnostic laparohysteroscopic resection in this cycle. I think you should speak to your gynecologist to ascertain the date of the surgery now, as it should be done ideally between day 5 and 11 of the cycles and when one is in the follicular phase, the endometrialization has been minimum.
Investigations to be done:
Diagnostic laparohysteroscopy.
Thank you doctor,
I need your valuable inputs. Due to constant coaxing from the family members, I visited another gynecologist on the third day of my withdrawal bleeding after stopping Duphaston. I told the doctor that I do not want to conceive immediately and want to solve the problems first. The doctor confirmed through second TVS ultrasound that the fibroid's projection into the endometrium was 20 mm x 21 mm and he was not willing for surgery soon. For PCOS, the doctor advised me a 1200 calorie diet combined with exercise and told me to immediately lose weight from current weight of 130 lbs. The doctor prescribed me Novelon tablet from the fifth day of the cycle until 21 days and then advised me to take a blood test on day 2 or 3 of the next cycle to check prolactin, AMH and LH. Do you think the course of treatment is fine? My mother-in-law is dead against surgery. I had less bleeding this month compared to last month, but cramps during the first day were too much. Is it possible that I had not ovulated in this cycle?
Hi,
Welcome back to icliniq.com.
As you have chosen a fresh gynecologist and as expected he or she has started from fresh again, ordering the investigation for PCOS first and checking your hormone levels again with LH (luteinizing hormone), FSH (follicle stimulating hormone) and AMH (anti-mullerian hormone) just to re-establish PCOS (polycystic ovary syndrome). The 1200 calorie diet to reduce weight was advised with the aim of decreasing insulin resistance and hence, will promote ovulation in PCOS. As your doctor is treating you for PCOS, he or she would have placed you on Novelon (Desogestrel and Ethinyl Estradiol), which is a low dose oral contraceptive for at least next three to six months to bring your hormone levels especially the androgens under check and reduce PCOS symptoms, promoting ovulation, which can be determined later by ovulation kits in each cycle after stoppage of Novelon.
As you mentioned that you are not keen on conceiving at present, so you basically consented to give the doctor, time to take care of problems first and pregnancy is not an issue for you at present. The Novelon is a combined oral contraceptive pill with estrogen and progesterone together. The estrogen component may increase the size of the submucous fibroid, that is a possibility and you may experience intermenstrual bleeding further. So, that is the consideration which your gynecologist has to keep in mind and have to keep checking for the increase in size with ultrasound monthly.
I feel treatment is PCOS oriented and not towards fertility and fibroid. If your plan is to wait, then you may continue. But, I do not think fibroid shall decrease in size with Novelon. Your mother-in-law may be against surgery, which is understandable completely. So, you have to make a decision to wait and decide that you do not want pregnancy for the next six months at least. Though, regularity still cannot be guaranteed in menses due to fibroid persistence. The less bleeding this time was secondary to Duphaston and the bleeding shall also be taken care of by Novelon. The cycle is difficult to vouch on ovulation now, as the only way to find out is mid cycle with ovulation kits. With Novelon, there would be no ovulation at all.
Thank you doctor,
I have discussed with you everything from the beginning. Kindly suggest the treatment of which doctor you think is better? Should I prefer the idea of laparoscopic ovarian drilling and then hysteroscopy for submucosal fibroid or the second of putting me on Novelon from tomorrow? I do not wish to change the doctors at all, but my mother-in-law is insisting as she thinks I may lose uterus during surgery. The Novelon containing estrogen and preventing ovulation is creating fear in me now. You are right that I did not give much importance to the fibroid. I can wait for three to six months, the earlier the better. I am already 31 and running out of time. I am really confused.
Please help.
Hi,
Welcome back to icliniq.com.
As you are seeking treatment for the sole reason that you intend to conceive and at present confused because you want the ovulation to get treated, then try natural conception. As known that there are two hindrances in it, PCOS and the submucous fibroid. Ideally, both should be treated simultaneously and there is no point delaying the treatment for the next six months in trying to rectify PCOS. As I told you earlier, PCOS is like diabetes. It can be controlled, but not treated. So, even after six months, you would have three to four months to conceive naturally. If the fibroid increases in size, then there may be a problem during implantation and further continuation of pregnancy even if you conceive.
My suggestion would be to go with your first doctor who plans a diagnostic hysterolaparoscopy and fibroid resection first. Then, after three months you can plan for an ovulation induction and intrauterine insemination to increase the chances of conception, even if the PCOS continues. After hysteroscopic removal of the fibroid, you can be placed on Folic acid tablets and Metformin tablets for next three months. Continue on low-calorie diet and exercise to control hormonal imbalance in the next three months post surgery. Your second doctor is just trying to control PCOS and not doing anything about fibroid, so I feel your first doctor is better.
The fear that you would lose your uterus is futile as no hysterectomy or removal of the uterus is performed during the surgery. It will be just shaving off excess submucous fibroid impinging into the cavity, which is 0.7 x 0.7 inch (large enough).
Thank you doctor,
I have finally made up my mind for the surgery, but I have not taken the Gonablok tablet as prescribed by the first doctor. If the submucosal part of the fibroid is resected, will there be any remaining part still inside the uterus and can it pose a problem during pregnancy? If hysteroscopy is the procedure to remove the projected part, then by what procedure the part inside the uterus can be removed? How long should I take bed rest after such surgery?
Hi,
Welcome back to icliniq.com.
It is nice to learn that you have finally made up your mind for hysteroscopic fibroidectomy. If you have not taken Gonablock (Danazol) as advised, still it is fine. You should visit your gynecologist soon now, as she would like to perform the surgery between day 5 and 10 between the early follicular phase. The resection would be of only protruded submucous fibroid till the basal lamina for endometrial growth and the remaining fibroid shall remain inside the myometrium. But, that will not affect the pregnancy as endometrium shall regrow over the shaved surface of inner wall of the uterus and the best time to conceive shall be after the surgery within the next six months. Once you get pregnant then the estrogen, which is the cause of fibroid growth, would be decreased and replaced by progesterone, which is the supporting hormone of pregnancy. Hence, there would be no further growth of the remaining fibroid till pregnancy is terminated.
The remaining fibroid after resection need not be removed till pregnancy is over. However, the regrowth shall take time and if it encroaches the endometrium again, then hysteroscopy would be again an option as the removal would not be possible laparoscopically. However, it is seen that the uterus sometimes naturally extrude the fibroid out. That can take some time and often such cases present with pedunculated submucous fibroid with increased discharge, but that is for the later to be decided. The present aim is to achieve pregnancy post surgery. You will need to rest for 24 hours and post that, you can be discharged and placed on conjugated estrogens like Premarin for a week or two to allow endometrium to regrow.
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