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A cesarean scar defect a.k.a. the niche

By Robert on August 20, 2023

A cesarean scar defect is a complication that arises as a long-term consequence of a cesarean section. When women undergo a cesarean section, an incision is made inside the uterus to facilitate the baby’s delivery. Sometimes, this incision doesn’t heal completely, leaving a small opening inside the uterus where fluid can accumulate. This opening in the uterine wall is known as a cesarean scar defect or a “niche.”

A recent study involving nearly 2,500 women found that 60% to 70% had a niche following a cesarean section. Such a high occurrence makes one wonder if it’s not “normal” to have a niche. About 30% of these women have a “large” niche. To put this in perspective, the wall of the uterus is between 8 and 10 millimetres and a niche is called large when it’s bigger than half of the thickness. In other words, even a “large niche” is usually only 5-6 mm big.

Detecting a niche can sometimes be straightforward, especially if a significant amount of fluid is present, making it visible via ultrasound. However, its appearance might be subtle at times, necessitating the introduction of gel or water into the uterus to highlight the defect. The amount of fluid in the niche can also vary depending on where a woman is in her menstrual cycle, which means it can sometimes be overlooked in ultrasounds, particularly if the gynaecologist isn’t specifically trained to spot it.

Niches can also cause symptoms, which I will discuss in this blog post. So, if you’ve had a cesarean section and begin experiencing related symptoms afterwards, requesting a detailed ultrasound is a good idea. We’ve recently coined a term for this combination of a niche and complaints: “cesarean scar disorder.” Defined in 2023, this disorder has garnered significant media attention, which is positive. We truly believe it’s essential for women to understand that one of the long-term complications of a cesarean scar can lead to this disorder.

Cesarean scar disorder is typically diagnosed through a combination of ultrasound detection of a niche and symptoms like intermittent bleeding, pain during menstruation, or challenges with fertility. Primary symptoms are directly linked to the scar defect, and secondary symptoms often arise due to the primary ones. For instance, some women report an unpleasant odour, likely due to intermittent bleeding. Others may feel less hygienic and subsequently avoid sexual intimacy or struggle with infertility.

By itself, a cesarean scar defect isn’t necessarily problematic. However, cesarean scar disorder can be concerning and warrants a diagnosis and potential treatment. While I won’t delve into treatment options in this post, various methods are available. It’s crucial to remember that many women with a cesarean scar don’t experience the disorder, and among those who do, not all require treatment.

As of 2023, we’ve outlined the disorder’s criteria and diagnostic techniques, and we’re actively exploring optimal treatment methods to assist women facing this issue. If you believe you might have cesarean scar disorder, I’d recommend seeking expert advice.

What are fibroids, and why are they giving me complaints?

By Robert on June 7, 2023

Understanding Fibroids: Non-cancerous muscle growths in the uterus

Fibroids, also known as uterine fibroids or myomas, are non-cancerous growths that develop within the walls of the uterus. We will discuss these growths, covering their definition, prevalence, risk factors, symptoms, and diagnostic approaches.

Fibroids growths arise from the muscle tissue of the uterus and consist of abnormal cells and fibrous tissue. They come in different sizes and can be solitary or multiple. Currently (2023), we believe that fibroids grow based on the hormones oestrogen and progesterone. The ovaries make these hormones and are usually influenced by the brain and medication.

Fibroids are quite common. Research suggests that a significant number of women, estimated between 20% and 80%, may develop fibroids. The prevalence can vary depending on age, ethnicity, family history and genetic predisposition. African-American and Japanese women tend to have a higher incidence of fibroids and may develop them earlier than women of other ethnic backgrounds. However, no signs exist that lifestyles, such as diet and sleep, influence fibroids’ appearance or growth. In our hospital, we do a lot of research on fibroids, trying to determine which factors influence their growth. Because fibroids grow based on ovarian hormones, they always shrink after menopause.

While most women may not experience noticeable symptoms, others may encounter mild to severe complaints. The most common complaints are blood loss or bulky complaints. Fibroids can cause heavy or prolonged menstrual bleeding. Bulky symptoms, like pelvic pain or pressure, can be caused by the mass of the fibroid, which can be quite big. The bulk of the fibroid can also cause an increased frequency of urination. A more complicated problem is infertility. According to the FIGO classification, there are eight types of fibroids. But you can divide them into two clinically relevant groups: those inside or in touch with the uterine cavity and those growing more on the outside of the uterus. The first gives more complaints of bleeding problems, while the latter gives more bulky issues. Fibroids inside the uterine cavity can cause fertility issues, while those outside the uterus might not. More about fibroids and fertility in another blog post soon.

To uncover the presence of fibroids, the first step is a comprehensive medical history and a pelvic examination. Then an ultrasound scan is usually the first imaging technique. Preferably by vaginal ultrasound, even small fibroids can be visualised. MRI can be of added value when fibroids are very big or when it is needed to differentiate from something else.

Worries about cancer
Understandably, people may have concerns about fibroids and their potential to become cancerous. However, it’s important to note that fibroids themselves are non-cancerous growths. They are not inherently malignant, meaning they cannot transform into cancer. In extremely rare cases, a type of cancer called leiomyosarcoma can develop in the uterus’s smooth muscle tissue, where fibroids arise. However, it’s crucial to emphasise that leiomyosarcoma is extremely uncommon, accounting for less than 1% of uterine cancers. In the vast majority of cases, fibroids are benign and do not pose a risk of cancer.

In conclusion, fibroids are non-cancerous growths in the wall of the uterus. Although their exact cause remains uncertain, hormonal factors, genetics and age may contribute to their development. Understanding the definition, prevalence, risk factors, symptoms, and diagnostic approaches associated with fibroids is vital for early detection and appropriate management.

I personally see quite a lot of patients with fibriods. And it’s a very challenging problem, because many patiente either experience very little complaints. A fibroid can be found by coincidence or by a fertilty doctor. In my personal opinion one of the difficult things is the follow-up. We know from previous studies that fibroids grow about 1 cm per year. If a fibroid indeed grows that slowly, and someone has no complaints, it doesn’t make sense to check on it every year. But sometimes they grow faster. We might be able to determine with doppler ultrasound which fibroids grow faster, but not yet. And if a fibroid grows bigger, but still gives no complaints, should you treat? When should you treat something to prevent complications? And how many side-effects or risks should you accept? These are the complicated questions I discuss with my patients on the Amsterdam UMC Uterine repair center. I will discuss treatment in a different blog post.
Robert de Leeuw

If you have any personal experiences, thoughts, or additional insights about fibroids, we invite you to share them in the comments below. Your input may provide valuable perspectives and support for others navigating this common condition. Let’s foster an open and informative discussion about fibroids.

Introduction of the Dutch Doctor

By Robert on June 6, 2023

Empowering Women’s Health: A Journey through Gynecological Surgery, Adenomyosis and Endometriosis

Introduction
Welcome to my blog dedicated to women’s health, gynecological surgery, and the complexities of endometriosis and adenomyosis. My name is Robert de Leeuw, and I’m a passionate and experienced specialist in gynecological surgery. Currently (2023) working at the uterine repair center in the Amsterdam University Hospital in the Netherlands (hence, the name the Dutch Doctor). Through this platform, I aim to share knowledge, empower women, and foster a supportive community. Let’s delve into why I embarked on this journey, my goals, and the content I will focus on.

Why Start the Dutch Doctor Blog?
As a gynaecologist, I have witnessed firsthand the transformative impact that knowledge and support can have on patients. However, I realized my reach was limited to those visiting me in the hospital. I wanted to extend my expertise beyond these boundaries and reach a wider audience. The online community can be very opinionated, with many layperson opinions posed as hard facts. I will engage with these online conversations through this alterego, The Dutch Doctor writing a blog and my YouTube channel (YouTube.com/@thedutchdoctor).

The blog and YouTube channel give me a unique opportunity to connect with individuals globally. I believe in the power of education and awareness in empowering women to make informed decisions about their health. Through these platforms, I can contribute to breaking the barriers of misinformation and stigma surrounding gynaecological conditions.

The Dutch Doctor blog goal and topics

Education and Empowerment: My primary goal is to educate and empower women. By providing accurate and reliable information, I aim to bridge the knowledge gap and help women understand their bodies, the various gynaecological conditions they may encounter, and the available treatment options. Empowered women can take charge of their health and make informed decisions. Through detailed explanations, visual aids, and simplified terminology, I aim to make complex medical concepts accessible and understandable for everyone. My blog is my personal and professional opinion at the time of writing. Medicine is a quickly changing field, and what is true today can be old tomorrow. Please keep that in mind. Also, this blog is mine and does not represent my employer in any way.
Awareness and Support: Another crucial aspect of my endeavour is raising awareness about menstrual illnesses like niches, fibroids, adenomyosis and endometriosis. Through my content, I strive to shed light on these complex disorders, their symptoms, diagnosis, and available treatment modalities. Adenomyosis and endometriosis especially, are often misunderstood and misdiagnosed, leading to years of suffering for many women. I aim to provide comprehensive information that helps individuals recognize the signs, seek timely medical intervention, and access appropriate care.
Discuss Healthcare Provider Efficiency: Besides providing information to patients and individuals seeking knowledge about gynaecological surgery and endometriosis, I recognize the importance of supporting healthcare providers. Through this platform, I aim to engage in discussions focusing on enhancing efficiency, work ethic, time management, and professional development for healthcare providers.

The Dutch Doctor with my trusted ultrasound machine, many thanks to Samsung.

In conclusion, my blog and YouTube channel are dedicated to empowering women through education, support, and community engagement. By sharing knowledge about gynaecology, uterine procedures, adenomyosis and endometriosis, I aim to bridge the gap between medical expertise and public understanding. Through accurate information, personal narratives, and interactive discussions, I hope to inspire individuals to take control of their health, make informed decisions, and confidently navigate their healthcare journeys.

Do you want to read more about me as a person, go the the about page here.

Join me on this exciting endeavour as we embark on a journey toward empowering women’s health. Together, we can create a community that fosters understanding, support, and empowerment for all those affected by gynaecological conditions. Let’s uplift, educate, and advocate for women’s health, one blog post and video at a time.

Thank you for being so supportive, and I look forward to sharing this transformative journey with you!