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Female Problems - Vagina / Uterine

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - I am considering having the contraceptive intrauterine device (IUD) fitted. Are there any risks that the coil could be crushed, pushed out or even damaged while diving due to the pressure on the body at depth? What about the contraceptive implant, does the pressure when diving interfere with the amount of hormones released?

A - Itís extremely unlikely that youíll encounter any problems with the IUD whilst diving. Most are small, solid structures that are snugly situated in the womb, protected from any harmful effects of external water pressure. Sometimes they do lead to increases in amount and length of menstrual flow, which might prove less than ideal on a liveaboard with one tiny toilet and 20 hairy male divers. But newer types such as the intra-uterine system (IUS) tend to diminish flow so itís probably wise to discuss the various options with your GP before plumping for one. Thereís no available evidence on whether pressure affects the release of hormones from the contraceptive implant, but thereís no theoretical reason why it should.

Q - Can I ask you about my naughty uterus? I suffered for years with menorrhagia and a month ago ended up having a vaginal hysterectomy with anterior repair. There were no complications and I'm healing very well: mobile, bowels great, bladder great, no infection. What I want to know is: I'm going to Mexico for some recuperation time. I want to do a swimming with dolphins excursion (not captive dolphins) that doesn't appear too strenuous. I'm not going to be able to see my gynaecologist before my departure. Would that be OK?

A - The last time I witnessed the admonishment of a uterus was as a lowly junior doctor on Birth Suite. The poor owner of this wayward womb was suffering regular contractions with a closed cervix, akin to trying to squeeze toothpaste out of a tube with the lid shut. The consultant on call, a fiery sort with the bedside manner of a vexed Vinnie Jones, stormed in, examined the patient, and said in a full Scots brogue: ďyou have a lovely cervix, my dear, but an extremely naughty uterusĒ. Incensed, she delivered soon afterwards, but itís not a technique that Iíve seen since.

I don't see a problem with some well earned recuperative swimming, as long as your wound is healed over and your blood tests (particularly your haemoglobin) show that you're not anaemic. With surgery of this kind (which is pretty major) I normally suggest a post-op layoff of 6-8 weeks to allow the tissues to develop reasonable strength before diving, but swimming should put a lot less strain on things, so the 4 weeks you have given it should be enough.

Q - I am having a LLETZ treatment under a GA this week to remove a second occurence of CIN2/3 cells. How soon after a GA and this type of treatment can I resume diving? All the hospital can advise is no lifting or swimming for at least 1 week following the treatment.

A - Acronym city hereÖ

GA= general anaesthetic.

CIN= cervical intraepithelial neoplasia.

LLETZ= laser loop errrr, forgot the rest, but it is removing the bad cells with a laser gizmo. Like Connery Bond on the table in Goldfinger.

UBE= unnecessary breast examination. Thought I would chuck that one in there.

A1W= answer, I week is ok for you.

Q - I am going in to hospital as a day surgery case to have a laparoscopic hydrotubation. How long till I can dive after this?

A - I think- no Iím sure this is the op where they pop the steel tube through your tummy button. Then whiz a fibre optic scope through that to look at your fallopian tubes. Then a whole bunch of blue dye is pumped up through the cervix, and is expected to be viewed passing from the ends of the fallopian tubes. Ergo, your tubes are fine, and there shouldnít be a problem getting pregnant.

No dye seen and itís a blockage. IVF all round then, and I bet you wished you had taken some zithromax to clear up the Chlamydia in your teens.

Good luck anyway, and give it 4 weeks before diving, as a rough rule of thumb.

Q - Is it OK to dive with large ovarian cysts ?

A - "Referee, I hope your mother has an ovarian cyst the size of a grapefruit". One of the better insults I have heard at Stamford Bridge in the last few years. So, Mrs Collina, listen up. It is fine, as long as they are not prone to something called torsion. That's where they twist on their own axis and cause a lot of tummy pain. If this happened underwater it could be an issue.

But I assume the gynaes would have removed them by now if this was the case. So dive on, as these fluid filled lovelies won't compress or burst with pressure.

Q - I did my PADI Open Water in November, ready for the Christmas diving I was about to embark on in Oz which was fantastic. I am itching to do my advanced but have just had a laparoscopy with diathermy to endometriosis and a Mirena IUS fitted. It was my 4th laparoscopy. The consultation afterwards informed me that they had removed all the endometriosis which they had not succeeded in doing previously. I have had very varied advice on when I can dive again ranging from 'when you feel up to it' to 'not for at least 6 weeks'. After the previous laparoscopy, had I then been a diver I would have felt up to it within about a week as I recovered so quickly. This time on the other hand, when I am desperate to get normal.... I insisted on a 3 mile walk the day after the op thinking it would build up muscles slowly and enable progression to running, swimming and diving. The walk, persistent cough (which is at last on its way out) and my four year old jumping on my stomach the next morning have not helped. I am still bleeding internally but that could be the Mirena. Externally there is hardly a trace, the lower cut just looks like a scratch and the one in my belly button is not much more, just a little bruised. So please could you let me know when I can dive?

A - I think if they have dived into you 4 times to frazzle the little bits of uterine tissue lying outside the womb, that causes endometriosis, and your little scamp of a child has been using you as a trampoline, then best to leave it for 6 weeks. I know this may be ultra-conservative, but it's no mean thing having this sort of op. glady we men will never suffer this problem, but basically, the womb lining somehow gets out of the uterus and into the fallopian tubes, the abdominal cavity and even into the uterine muscle too. Then each time you have a period, the hormones make this tissue expand as well, and get bloody, causing monthly agonizing pain. Thank the Lord for Y chromosomes. But its gone now for you. However 4 entries through the abdo wall with the scope can make healing less quick.

So leave it 6 weeks to be sure. The bleeding is due to the coil. Mirena is a progesterone covered coil, and this hormone can cause abnormal bleeding for a few weeks after it has been fitted, but all will be OK for when you first sign up for your Open Water.

Q - I had a vaginal hysterectomy on the 11th February, I'm 37 and generally fit and well I'm returning back to work on later this month. I'm driving not as much but a bit. My check-up after the op is not till 3 weeks from now.

A - There's 2 ways of doing a hysterectomy.

Vaginally where the surgeons go via that route, or abdominally where they go through a bikini line incision on your lower abdomen.

The advantage of the first method is that it does not involve cutting through your abdominal muscles. And so your over all recovery time is quicker as you can lift, strain and heave sooner. This naturally will benefit the diver as they rig up on a busy RIB.

I normally suggest that 6 weeks is a reasonable time to wait post-op before diving again.

But if it the first time for you and you are doing the OWC at their pool in Chiswick then a couple of weeks should be fine for the simple pool work and theory. Leave it another 3-4 weeks though before doing your 4 open water dives.

37 is quite young for this sort of op and it may be worth considering the implications of your condition that warrants this on diving.
If it for uncontrolled heavy periods, then that's fine. However if it's for any sort of tumour then we may need a rethink.

Q - I had a total hysterectomy, abdominal incision at the end of January this year, could you tell me when it would be safe to undertake diving again?

Also I am hoping to go to Scapa Flow in September as I'm sure you are aware this is 40+m depth and very adventurous diving, in your opinion do you think I will be fit enough to do this type of diving by then ?

A - My advice with this situation is pretty much standard. When you are fit enough to hump a bag of fertilizer from the car to the garden then you are fit enough to dive.

An incision has been made through your abdominal wall muscles to get at your uterus. Like any op of this category we say a good 8 weeks or more should be enough time for recovery. Some things delay recovery like post op infection or if you have any other illnesses that slow healing.

I would wait until the season starts, let's say the end of April, i.e. 3 months and you should be fine by then.

One thing on the Scapa trip. Do make sure you are dive fit and it's not the first dive after a lay off. The chamber up there is reporting more and more cases, so make sure a 40metre, low viz dive is like falling off a log for you before you go.

Q - I wonder if you could advise me please as my wife had a vaginal hysterectomy on the 8th Dec 2000 and is making a good recovery with hardly any bleeding whatsoever, she does get a few twinges every now and then but nothing she seem overly concerned about.

The big question is would you have any ideas when it would be safe to resume scuba diving, carrying out no decompression diving with a max depth of no more than 25 meters in warm waters.

A - Recovery from this sort of operation to full preop ability usually takes up to one month. The operation she has had has no real effects on diving, so I suggest she wait until she is fully able to act as a good buddy and be strong enough to help you if you get into any trouble. This also includes her strength in carrying her tanks and rigging up in difficult conditions. Anyway by now she should be fine to dive.

Q - I am very prone to getting bladder infections, which I treat with various over the counter remedies. However I am going on a long live aboard to the Red Sea and a friend has told me that I ought to take some antibiotics with me "just in case". My question is which ones and is there anything I can do to prevent it from happening?

A - Your friend is right. You suffer from what we call cystitis, which is where bacteria that normally inhabit your lower gastrointestinal tract can find their way to your bladder and multiply causing you the symptoms of pain on urination, increased frequency of urination and often an odd odour to your urine. The reason that women get it far more frequently than men is due to the length of their urethra. This is the tube that takes the urine from the bladder to the outside world, which in men is considerably longer than in women. So because of this bacteria can easily find their way up to the bladder and so cause the problem.

When you are back home the fact is that if the problem didn't get any better with the over the counter remedies you can quickly see your doctor who can prescribe you the antibiotics needed. But of course on safari you may be a long way from medical help and if left untreated the real problems can set in.

Leading into the bladder from the kidneys is another tube called the ureter, and in some cases the bacteria can ascend this tube and cause a full on kidney infection. This would lead to a severe fever, vomiting and pain in your lower back at the side of the infection. This can sometimes lead to dehydration, delirium and hospitalisation.

What I suggest is that you take your usual remedies with you, and if you get symptoms of cystitis then you should try these for a day. If there is no improvement after this then you need to really increase your fluid consumption to about 5 litres a day, especially as you will be in a hot climate and will be dehydrating at a faster rate than at home and you should start the antibiotics immediately.

There are several you can take, and currently I would suggest either trimethoprim 200mg twice a day for 3 days or cephalexin 250mg twice a day for the same time. The strongest and widest spectrum antibiotic is called ciprofloxacin and is taken at a dose of 100mg twice daily for 3 days as well.

If you are going for a long time I recommend you get hold of 2 courses of one of the first 2 and one course of the ciprofloxacin for your medical bag.

To prevent it occurring in the first place, always drink plenty of fluids, especially cranberry juice, make sure you wipe your bottom from front to back after going to the toilet and try to pass urine as soon as you can after intercourse as this can also aid the passage of bacteria up to the bladder.

On a final note, if you are suffering cystitis that often then you should make sure that your doctor has screened you for diabetes as this can make you prone to these recurrent infections.

Q - I have been having PROTECTED sex for the past week with a new partner. Now I am experiencing vaginal burning and it really burns/hurts on the right side of my vagina when I urinate. Also, my anus hurts/burns very badly too, especially when defaecating. I've also noticed a clear goo with blood in it coming from my anal area after going to the restroom. What is the problem and how can I fix it? This problem has been occurring for the past 4 days!I am diving the Catalina Islands in a week.

Help.

A - And you call it a restroom. Doesn't sound like a place of rest to me, but the torture chamber for double-bottom disasters.

First the good news, none of your problems is a bar to diving. Depth, saltwater and neoprene are all OK as long as you have a sturdy pair of knickers.

But at the very least you could have a urine infection in the front and a bleeding pile at the back. Let's not go into the worst case scenario. You won't sleep.

Get yourself to a doc, who will examine you appropriately and hopefully nail it with tablets and cream.

Tell your partner to get checked as well.

(other dive medical questions)



   


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