NOTES - Scarless surgery for stomach pain from menstrual irregularities

• Menstrual irregularities can cause any of the following symptoms: frequent menstruation, a longer-than-usual cycle, slight bleeding during the middle of a cycle, or abnormally painful stomach cramps. Seek medical attention if any of these symptoms occur. 
• Natural orifice transluminal endoscopic surgery (NOTES) is a form of scarless surgery that involves inserting surgical instruments into the abdomen via the vagina. It is considered extremely safe due to the lack of skin damage, reduced blood loss, and rapid recovery times. 
• There are several conditions or menstrual irregularities that can be treated using NOTES, such as uterine fibroids, ovarian fibroids, cystic ovaries, and endometriosis (if not too big). 

As women reach reproductive age, their ovaries begin to produce estrogen before ovulation, while stimulation in the hypothalamus and pituitary gland results in signs of puberty, including getting their period and growing taller within the first 1–2 years. There are also several internal changes that take place at this time, such as enlargement of the uterus, thickening of the endometrium, cervical mucus production, and increased ovary function, all of which are in preparation for bearing children. However, the complex nature of the female anatomy, especially during the reproductive stage, requires careful attention. Women must be observant for any irregularities – however innocuous they may seem – including stomach pain, which could indicate a serious or dangerous illness.

Over 90% of post-pubescent women experience stomach pain during their period, although this pain usually tends to sit somewhere around 4/10 on the pain scale. However, should women aged 40–50 experience severe pain that worsens over time until it reaches between 7/10 and 10/10 on the same scale, this is considered dangerous because it could signify a more serious disease, such as a fibroid which may develop into cancer. Therefore, should such symptoms present themselves, the woman should undergo a medical diagnosis and receive any necessary treatment.

Given that the uterus is a reproductive organ located in the lower abdomen, any irregularities affecting it will tend to cause slight pelvic pain, although such pain may or may not be associated with a uterus issue. Examples of other problems capable of causing pelvic pain include fibroids pressing on the bladder, constipation, and regular period pain. Only pain that develops into a serious issue requires medical attention and rapid diagnosis.

Girls are hitting puberty at younger ages, however, it is most common for puberty to occur after 11 years of age. Healthy women will have a menstrual cycle every 21 to 35 days. Typically lasting 2–5 days, the period of a healthy woman may require approximately 2–3 sanitary pads per day and involve stomach pain rated at 4/10 or less on the pain scale. 

However, in cases where the following symptoms occur, a doctor’s appointment should be made to receive advice, undergo a physical examination, and receive any necessary treatment: 

1. Not getting the first period until after the age of 16 may signal a pituitary tumor, lack of ovaries, or the presence of a menstrual issue, such as a vaginal obstruction or imperforate hymen. 
2. Not getting a period for 5–6 months in a row may be a sign of a pituitary tumor, stress, hormonal irregularities, or emotional issues that can cause mood swings and frequent losses of temper. 
3. Never getting a period, despite reaching reproductive age, is mostly caused by hormonal irregularities or an obstruction, such as an imperforate hymen or cervical stenosis, or the lack of a uterus, ovaries, or ovary function. 
4. Overly frequent periods (every 1-2 weeks), a longer-than-usual cycle, slight bleeding during the middle of a cycle, or abnormally painful stomach cramps (measuring 7/10–10/10 on the pain scale) can all be caused by any of the following conditions: hormonal abnormalities, cervical polyps, uterine fibroids, endothelial tumors, ovarian tumors, endometrial hyperplasia, endometrial cancer, cervical cancer, or issues associated with blood clotting. 

• Review of the patient’s medical history: Patients will first be asked about their symptoms, such as the nature of their stomach pain and how much bleeding occurs during their period. 
• Physical examination: The general health of the uterus will be assessed by the doctor, including a pelvic examination (screened via the vagina or anus) and, in some cases, a breast screening. 
• Ultrasound scan: This scan provides a clearer pathological picture of the uterine cavity and comes in two main forms: abdominal ultrasound and vaginal ultrasound. Vaginal ultrasound offers a clearer image of the uterus’ internal structure and any irregularities, although ultrasound via the anus may be used to provide additional information. 
• MRI scan: Used in cases where the above screening methods are inconclusive from a pathological perspective, MRI scans are popular because they offer a much clearer image of the tissue than other methods and are suitable for use in pregnant women. 
• CT scan: Also used where the above methods remain inconclusive, CT scans can confirm a diagnosis but are not suitable for use in pregnant women. 
• Endoscopic surgery: Such procedures are used for diagnosis when the aforementioned methods have been unsuccessful, or in cases where other screening methods cannot be used. Endoscopic surgery enables immediate treatment of certain conditions, including ovarian tumors, although such procedures must only be carried out by highly experienced surgeons. 

1. Non-surgical treatments include pain relief medication for cases where period pain is not severe. 
2. Surgical treatments may be suitable for patients who have been unsuccessful in treating their condition with pain relief medication or where it has been recommended by a doctor. Surgery must only occur after review of the symptoms, physical examination, and other detailed forms of screening have been used to confirm that surgical treatment is the most suitable option. Surgery can usually be used to treat the following conditions: adenomyosis, uterine fibroids measuring larger than 4–5cm, internal abdominal or uterine bleeding, endometrial polyps, stomach pain in conjunction with period abnormalities, pelvic adhesion, and ovarian endometrioma. 

• Open abdomen surgery: Involves making a large incision in the abdomen through which surgeons can then access the abdomen or uterus. The incision leaves a relatively large scar, rehabilitation times can be lengthy, and there is a risk of side effects such as infection or adhesion formation. 
• Endoscopic surgery: Involves inserting an endoscope into the abdomen or uterine cavity. This is currently the most popular form of surgery and comes in 2 main types: 
  • Laparoscopic surgery 
    Between 3 and 5 tiny incisions measuring 0.5–1.0cm in length are made in the patient’s abdomen. An endoscope is then passed through these incisions to diagnose and remove fibroids or membranes, such as ovarian tumors, myoma uteri, endometrial hyperplasia, endometriosis, or pelvic adhesion. The benefits of this method include minimal scarring, only slight blood loss, rapid healing times, and reduced overall recovery time. 
  • Hysteroscopic surgery 
    This technique involves passing the endoscope into the uterus via the patient’s cervix in order to diagnose uterine irregularities such as uterine polyps or fibroids, and to allow immediate treatment without the need to open the abdomen.  

In addition to these procedures, innovations in the field of endoscopic surgery have led to a new technique known as NOTES (Natural Orifice Transluminal Endoscopic Surgery) being developed.

This technique involves inserting an endoscope and surgical instruments into the abdomen via natural orifices, such as the vagina or anus, completely eliminating scarring. Nonetheless, NOTES is not suited to patients suffering from larger fibroids, chronic endometritis, or multiple pelvic adhesions, which may have developed naturally, been caused by a prior surgical procedure, or resulted from numerous cancerous tumors.

NOTES can be used to treat the following conditions or irregularities:

• Uterine fibroids
• Some forms of ovarian fibroids
• Cystic ovaries measuring 3–4cm 
• Endometriosis or chocolate cysts measuring 3–4cm 
• Endometrial hyperplasia
• Benign endometrial disorders
• Cervical cell irregularities with the potential to develop into cancer.

• Extremely safe 
• Minimal blood loss and rapid recovery times 
• No abdominal scarring 
• Minimal time off from work 
• Reduced costs associated with in-hospital recovery 

• Shower normally following surgery 
• Avoid hot and spicy food for 1 month  
• Avoid sexual intercourse, swimming, immersing the affected area in water, and diving for at least 3 months 
• Be careful not to fall when walking up and down stairs and avoid lifting heavy objects for at least a month to prevent bleeding 
• Avoid cooking at a hot stove or eating overly spicy dishes for at least a month because this can lead to blood loss 
• Driving is permitted after a month, but speed should be kept to a minimum to ensure no heavy bumps or impacts to the affected area 
• Take medication and attend all appointments as requested 

Conclusion 

While it is entirely normal to experience some stomach pain during your period, chronic pain that worsens over time or excessive period bleeding are considered causes for concern. In such cases, a doctor’s appointment should be made to undergo a thorough diagnosis and treatment. Overlooking these symptoms can be dangerous.

Fortunately, technological progress in the field of medicine has led to an innovative new technique being developed known as NOTES, which gives patients another option to consider when deciding on treatment for their condition. The benefits of NOTES are its extremely high safety record, minimal blood loss, rapid rehabilitation times, affordable cost due to decreased time spent in hospital and, crucially, a complete lack of abdominal scarring to ensure the body confidence of patients remains unaffected.

Makawan Tananunkul, M.D. 

With over 37 years of experience as an obstetrician and more than 3,000 endoscopic uterus surgery procedures spanning 4 decades, Makawan Tananunkul, M.D. is considered an expert in all forms of endoscopic surgery, including NOTES, which requires a higher level of expertise than traditional laparoscopic or hysteroscopic procedures to ensure its success.