A Q&A session with Dr Musa

Q: What is your top tip for people struggling to fall pregnant?

A: For females, the peak fertility age is 24 and fertility declines with advancing age, so start early if you can and if your work commitments or social situation don’t allow, then consider egg freezing in your mid-thirties.

Q: What has been your most memorable day at work?

A: The day a couple I had taken through the obstetric journey, who had struggled to fall pregnant for 16 years, at 42 finally achieved a pregnancy and delivered a healthy baby, who must be about 5 years old now.

Q: What is the most common fertility issue you see?

A: Polycystic Ovarian Syndrome (PCOS). Weight management plays a key role here and I cannot reiterate enough the importance of weight management and its effect on fertility, even in non-PCOS patients.

Q: Where do you see the future of assisted fertility services heading?

A: I think with the increased uptake of preimplantation genetic diagnosis (PGD) (genetic screening), we will be able to achieve more successful IVF outcomes faster, especially with older couples, by prioritising chromosomally normal embryos for implantation.

I think we will also be seeing more single females who are financially and emotionally ready, but not in a stable relationship, utilising donor intrauterine insemination (IUI) services to achieve motherhood. I personally think it is great that at City Fertility we can help them achieve a family of their own.

Q: Where were you born and raised?

A: I was born in Fiji and moved to New Zealand at the age of 15 where I completed my medical degree. I still feel close to both these countries and now enjoy living in Australia as well.

Q: What do you like about living in Brisbane?

A: The weather and the easygoing people. I love how people comment “too easy”!

Q: What do you like to do in your spare time?

A: I like to spend time with my friends and family (I’m a mother of two). My long working hours often mean I’m not around as much as I’d like to be, so I take every opportunity to enjoy the precious moments together.

Q: Where is the most interesting place you have travelled?

A: I would have to say Japan. Having previously seen some amazing European architecture, ancient ruins etc., I was unsure if I wanted to go to a very modern Japan. What stunned me was the people! They were polite and courteous, eager to help even if they couldn’t speak English. The cleanliness was remarkable and how safe we felt, too. Of course, there is also amazing architecture like the Golden Pavilion and Kyoto, but it was the people that amazed me the most.

Scientists closer to pinpointing cause of PCOS

Polycystic ovary syndrome (PCOS) is the most common cause of female infertility, with one in five women affected by it worldwide, and roughly three-quarters of these women struggling to fall pregnant. Until now the cause has been unknown, but researchers have recently found that it may be caused by a hormone imbalance in pregnancy that is passed on to the baby.

Excess exposure in the womb to a hormone called anti-Müllerian hormone (AMH) may trigger the PCOS syndrome before birth.

The French National Institute of Health and Medical Research found that pregnant women with PCOS have 30 per cent higher levels of AMH than normal. Since the syndrome is known to run in families, the researchers wonder whether this hormonal imbalance in pregnancy might induce the same condition in the daughters of those affected.

Putting the theory to test on mice in a laboratory setting, the researchers found the AMH excess raised the level of testosterone, but this was able to be reversed using cetrorelix, an IVF drug routinely used to control women’s hormones.

The team is now planning a clinical trial of cetrorelix in women with the condition, and hopes to start before the end of the year. The researchers hope it will minimise the symptoms of PCOS and result in restoring ovulation and eventually increasing the pregnancy rate in these women.

Until these results are known, here is a summary of how PCOS can currently impact fertility and what treatment options are available:

How can PCOS impact fertility?

PCOS can have a substantial impact on fertility due to the abnormal progression of the ovarian follicles. Normally during the month, the follicles go through certain hormonal cycle responses and they reach a stage when there is a release of an egg through ovulation. Then if fertilisation with a sperm occurs, an embryo can be created. However, with PCOS, there is abnormal follicular growth in response to the hormone cycle, often followed by a lack of ovulation, and progesterone is produced, causing significant subfertility with unopposed estrogen. This not only affects fertility but also other aspects of health.

What are the treatment options for PCOS?

If fertility is the main priority for a woman with PCOS, the first line of treatment, which can have a huge impact, is lifestyle, diet and exercise. A healthy lifestyle improves all of the symptoms of PCOS, including fertility. If an overweight woman loses at least 5 per cent of her weight, she can sometimes go to spontaneous ovulation on her own. Her chances of not only getting pregnant but sustaining a healthy pregnancy with a good outcome are significantly improved. Lifestyle should never be underestimated.

The second step is ovulation induction, which can be done by clomiphene citrate (Clomid or Serophene), which is a tablet, through a certain regimen, or can be done with an FSH injection of a small dose. It depends on the clinical scenario. Up to 40 per cent of women using clomiphene will have success in ovulating, resulting in pregnancy rates comparable to those of the general population. Both ways, they need support through the process, clinically and personally.

If infertility is not the immediate concern, the combined oral contraceptive pill (OCP) can be prescribed to reduce acne and hirsutism and maintain regular menstrual periods. Most importantly, the OCP provides constant progesterone to protect the endometrium and decrease the risk of uterine cancer from the unopposed estrogen that is a common feature of PCOS.

Women with PCOS also need second-yearly Glucose Tolerance Tests (GTT) and regular metabolic screening such as a cholesterol check.

Unfortunately, PCOS is a chronic condition (just like asthma is), and while women living with it can never completely be free from it, they can control and minimise the effect of it on their life and health through careful management with their healthcare professionals. The results of the abovementioned study will also be interesting to follow, potentially resulting in new treatment options for women with PCOS into the future.

TELEHEALTH

 As of 31st March 2020, all Australians are eligible for telephone/video bulk billed consults with their GP or Specialist.  New patients will require a referral from their GP to see a Specialist.  Depending on the patient’s individual circumstance their GP may offer a Specialist referral though Telehealth.    

While Healthcare services are working hard to minimize unnecessary travel and promote social distancing, we do not want people leaving problems unaddressed due to coronavirus fears.  As clinicians we want to make sure people are keeping on top of their health issues, because the reality is that, impacts from COVID-19 will affect us all for many months to come. It is important to address medical concerns early to avoid a worsening situation down the track.  

If you have a Gynaecological concern and unsure whether it needs urgent attention – let your clinician help you make that decision via a Telehealth consult.  However, not all cases can be dealt with remotely – your clinician will advise if they need to review you in person at the Clinic. We can also decide whether it is best to postpone treatment or not.  

Although we are ceasing non urgent surgery to help conserve medical resources,  patients with urgent concerns like  acute pelvic pain secondary to ovarian torsion, ruptured ectopic pregnancy , heavy menstrual bleeding leading to low blood count  and other critical conditions  that may require surgery will still be able to access these services. In an emergency please present to your nearest A & E department or call for ambulance if needed. 

Cervical Screening Test (CST)

Cervical Screening Test (CST)

Cervical screening has changed in Australia. The Pap test has been replaced with a new Cervical Screening Test every five years. The latest medical and scientific evidence shows the new Cervical Screening Test is more effective at detecting the human papillomavirus (HPV) that causes cervical abnormalities, at an earlier stage.

It is expected that the changes to the National Cervical Screening Program will protect up to 30% more women from cervical cancer.

An increased understanding of cervical cancer and the changes made to the test means you can be confident that the new Cervical Screening Test is a more accurate, effective and safe test to have every five years instead of the two yearly Pap test.

What is the Cervical Screening Test .

Cervical Screening is done to detect potentially pre-cancerous and cancerous processes in the cervix.

With the new screening program, cells from the cervix are tested for HPV infection that may lead to cancer in the future

How is the cervical screening test done.

The test is done exactly the same as a Pap test. You will still have an examination using a speculum so that the cervix can be seen properly to take the sample of cells for HPV testing. The sample is collected using a special brush which is then placed in a container of liquid and sent away for testing.

Why do we need the change ?

New knowledge and technology means the cell changes that could lead to cervical cancer can be found sooner. Over 99% of cervical cancer is caused by the human papilloma virus (HPV). The new test looks for the presence of the HPV virus rather than looking for changes in cells that can occur because of the virus

I have had the HPV vaccine . Do I still need the CST ?

Yes. If you’ve had the HPV vaccine it’s still important to have your regular CST. The vaccine prevents most types of HPV infection but it does not prevent all types that can cause cervical cancer. Talk to your doctor if you missed out on the HPV vaccine at school as it may still be useful for you to have it.

When Do I need to have a Cervical Screening Test

The screening age has changed from age 18 to 25 as research has shown that beginning cervical screening at age 25 years is safe.

If you are turning 25 years old, or have never had a Pap smear before, you should make an appointment with your health care provider to have a Cervical Screening Test.

If you are aged between 25-74 you should have your first Cervical Screening Test 2 years after your last Pap smear. Once you have had your first Cervical Screening Test, you will only need to have a test every 5 years instead of every 2 years unless your results are abnormal.

If you have had cervical screening abnormalities in the past, follow your health care provider’s advice.

What if I have any concerns and need earlier testing than 5 years

If you have irregular bleeding or other symptoms that your doctor feels needs a earlier screening it will be done for you.

What happens if I have an abnormal result

Your healthcare provider will receive your results about two weeks after your test and will contact you about your results if abnormal.

If your CST is positive for any high-risk types of HPV (the types most likely to cause cervical cancer) the laboratory will automatically carry out a second test to look for changes in the cells of the cervix called liquid based cytology (LBC).

If your CST is positive for HPV-16 or HPV-18 or if you have a high grade LBC you will be referred to a gynaecologist for an examination called a colposcopy.

Colposcopy is a close examination of the cervix under magnification. Dr Musa performs colposcopy in her office and if any cell changes are found, a sample of tissue (biopsy) will be taken from the cervix and sent to the lab for further testing. The results usually take a week to come back.

If the biopsy is high grade than we can do a LLETZ procedure in either  Greenslopes Private or Sunnybank Private Hospitals .

Does the Cervical Screening test detect all Gynecological cancers

No it does not,  the cervix is the opening of the uterus (neck of the womb)

The cervical screening test only guides us about cervical abnormality.

Currently there is no effective screening for endometrial or ovarian cancer so even if your CST is normal and you get abnormal bleeding , abdominal mass or other gynaecological concerns you still need to see your doctor or a gynaecologist  for assessment.

 

POLYCYSTIC OVARIAN DISEASE (PCOS)

What is PCOS?

PCOS is a condition that affects your periods, fertility, appearance and hormonal balance.

Women with PCOS are more likely to have irregular prolonged periods, occasionally absent period, difficulty in getting pregnant, overweight and difficulty in losing weight, excessive hair on face, arms, back and excessive acne with oily skin.

Ultrasound may show poly-cystic ovaries, however this does not  always indicate diagnosis of the condition.  Also, women having just poly-cystic ovary on ultrasound and no other symptoms does not necessary have PCOS.

What causes PCOS?

The cause of PCOS is not yet known but it often runs in families.  If any of your relatives (mother, aunts, sisters) are affected with PCOS, your risk of developing PCOS may be increased.

The symptoms are usually related to abnormal hormone levels ie elevated androgens and insulin resistance.

How is PCOS diagnosed

Medical history, examination, pelvic ultrasound and blood tests are needed to make definitive diagnosis.

Management

Your doctor will discuss management with you based on your symptoms and the appropriate treatment option.

Irregular, absent periods is usually managed with hormonal medications and occasionally metformin can help.  Excess hair can be managed by waxing, laser hair removal or by reducing the amount of androgens in the body.  Hormonal contraception or anti-androgen drugs e.g. cyproterone acetate can help with this.  There are stronger medication available which your doctor will discuss if simpler options do not work.

Not all patients will need treatment to fall pregnant though in some cases it may take longer to fall pregnant as you do not ovulate every cycle and ovulation may be delayed depending on your cycle length.

If infertility is a concern then it is important to seek Medical help as usual.  Simple measures like weight loss and ovulation induction tablets can help. Occasionally IVF is needed to achieve pregnancy

ABNORMAL PAP SMEAR

What is cervical cancer screening?

Screening tests can find early problems before you get sick.  The Pap test is a screening test for cervical cancer. It looks for abnormal cells on your cervix that could turn into cancer over time. That way, problems can be found and treated before they ever turn into cancer. It is important to know that no screening test is 100 per cent accurate.

Understanding your Pap smear results

Having a Pap smear every two years offers the best chance of preventing cervical cancer.

The Pap smear is a quick and simple test used to check for changes to the cells of the cervix that may lead to cervical cancer. A doctor or nurse takes a sample of cells from the surface of the cervix and sends to a laboratory for analysis and the results are usually available within a week.

Most Pap smear results are normal. A small number show changes in the cells of the cervix; mostly minor infections that usually clear up naturally or are easily treated. In a very small number of cases the abnormality persists and if left untreated, may develop into cervical cancer. When detected early, changes to the cells of the cervix can be treated.

When should I have a Pap smear?

All women between the ages of 18 and 70 should have a Pap smear every two years.

What is HPV?

HPV is a common virus – Human Papilloma Virus.  There are several types of HPV.

Some HPV types can cause changes on a woman’s cervix that can lead to cervical cancer over time.

Other HPV types can cause genital warts. But the HPV types that can cause genital warts are different from the types that can cause cancer.

Most of the time, the body’s immune system fights off HPV naturally within two years– before HPV causes any health problems.  It is only when HPV stays on a woman’s cervix for many years that it can cause cervical cancer.  We do do not know why HPV lingers in certain cases but not others.

How could I get HPV?

HPV is passed on through intercourse. Most people never even know they have HPV, or that they are passing it to their partner. So it may not be possible to know who gave you HPV or when you got it.

HPV is present in 99.7 per cent of cervical cancer cases. However, not all HPV infections lead to cervical cancer.

HPV is NOT the same as HIV (the AIDS virus).

What about the vaccine for cervical cancer?

Vaccines are now available that prevent the common types of HPV infection that cause cervical cancers. Currently the available vaccines do not protect against all the types of HPV that can cause cervical cancers. All vaccinated and unvaccinated women still need regular Pap smears.

What is an unsatisfactory Pap smear?

An unsatisfactory Pap smear means that the laboratory staff could not see the cells well enough to give a report.

In this case, you may be asked to have a repeat Pap smear. This is not a cause for alarm.

What does an abnormal Pap smear result mean?

An abnormal Pap smear result means that some cells from your cervix looked different from normal cells. This occurs in around 1 in 10 Pap smears.

It is natural to feel anxious or worried if you have just found out that your Pap smear result is abnormal, however less than one per cent of abnormalities are cancer.

Low Grade Abnormality

If you have a low grade abnormality and your previous Pap smears were normal, your doctor will ask you to come back for a repeat Pap smear in one year. Low grade abnormalities result from slight changes in the cells of the cervix, which may be the result of a mild infection such as thrush or HPV or lack of oestrogen at menopause. Or it could be a early sign of precancerous lesion.

High Grade Abnormality

High grade abnormalities can result in more severe changes to the surface layers of the cervix. If left untreated they have a greater chance of developing into cervical cancer.

It usually takes at least 10 years before high grade abnormalities develop into cervical cancer(as long as you are having regular pap smear). If you have a high grade abnormality your doctor will refer you to a specialist for further investigations and treatment.

How will I know when to have my next Pap smear?

Most doctors have an established recall system to notify you when your next Pap smear is due.  Most state health departments have established Pap smear registries that provide a safety net recall system although you can opt out.  Remember, if you have any concerns or questions, please contact your doctor.

Management after referral to Dr Musa

This will include:

Colposcopy – a colposcope (an instrument that magnifies the cells of the cervix) and gives a closer view of the extent and nature of the problem

Occasionally, cervical biopsy – a small tissue sample from your cervix is removed during the colposcopy and sent for examination in a laboratory.

Treatment of pap test abnormalities

If a high-grade abnormality is confirmed with cervical biopsy (usually takes a week for results to get back from lab), recommendation is to remove the abnormal cells from your cervix.

Dr Musa usually performs a LLETZ – Wire-loop excision – where the abnormal area of cervix is removed using a loop of wire. This acts as a treatment as well as further diagnosis for deeper abnormalities not picked up with a biopsy.

Pap tests after treatment

Women who have had treatment for high-grade abnormal cell changes need more regular pap tests for the first two years following treatment.

Endometriosis

 

Endometriosis is a chronic condition characterised by the growth of endometrial tissue in sites other than the uterine cavity, most commonly the pelvic cavity (including the ovaries)

Adenomyosis is the invasion of the middle layer of uterus by endometrial tissue. This leads to painful as well as heavy periods.

Extrauterine endometrial tissue causes inflammation, pain and the formation of adhesions.

Endometriosis is estimated to affect 5-10% of women of reproductive age

Risk for first-degree relatives of women with severe endometriosis is six times higher than that for relatives of unaffected women.

Aetiology

We are still unclear regarding cause for endometriosis. Suggested theories have included:

Retrograde menstruation.

Lymphatic or haematogenous spread.

Metaplasia.

Presentation

Common symptoms include:

Painful periods

Painful intercourse

Cyclical or chronic pelvic pain.

Subfertility

The clinical presentation is variable, with some women experiencing several severe symptoms and others having no symptoms at all.

Investigations

For a definitive diagnosis of endometriosis, laparoscopy is the gold standard investigation but it is invasive with a small risk of major complications – eg, bowel perforation.

Pelvic Ultrasound is advised to assess for Endometriomas- (ovarian cyst).

 Management

The treatment of endometriosis is usually individually based, depending on the nature and severity of symptoms and the need for future fertility.

Medical treatment may reduce symptoms in some of patients, but none of the treatment options has been shown to reduce recurrence of symptoms once treatment has stopped.

Surgical options include removing severe and deeply infiltrating lesions (which may reduce pain related to endometriosis), ovarian cystectomy (for endometriomas), adhesiolysis, and bilateral oophorectomy (often with a hysterectomy).

Management may also include pain management specialists and clinical psychologists.

Prognosis

The natural course of the disease is variable and may or may not be progressive.

In the five years after surgery or medical treatment, 20-50% of women will have a recurrence.