Conditions & Treatments

Dr. Rebeles provides comprehensive care for women with conditions such as abnormal uterine bleeding, uterine fibroids, pelvic pain, endometriosis, pelvic organ prolapse, stress urinary incontinence, ovarian cysts and options for permanent sterilization. When you meet with Dr. Rebeles, she will thoroughly evaluate your condition and discuss in detail all the options available to treat your condition, both surgical and non-surgical.

Gynecologic surgery has evolved rapidly in the past few years. New surgical and non-surgical options have recently emerged for a variety of gynecological conditions, with major emphasis on minimally invasive and non-invasive options.

Should you require surgery, Dr. Rebeles is a highly trained gynecologic surgeon who is an expert in minimally invasive surgery. She strives to provide a safer and more effective alternative to traditional open surgery by performing the vast majority of her procedures via laparoscopy, hysteroscopy or with the assistance of the daVinci Robotic System.

Diagnosis
Abnormalities in the menstrual cycle are common. Bleeding in any of the following situations is abnormal:
  • Bleeding between periods
  • Bleeding after sex
  • Spotting anytime in the menstrual cycle
  • Bleeding heavier or for more days than normal
  • Bleeding after menopause
  • Menstrual cycles that are longer than 35 days or shorter than 21 days are abnormal. The lack of periods for 3–6 months (amenorrhea) also is abnormal.
Based on your symptoms, laboratory or imaging tests may be ordered to help determine the cause of the abnormal bleeding. It may be helpful to keep track of your menstrual cycle before your visit. Note the dates, length, and type (light, medium, heavy, or spotting) of your bleeding on a calendar.

Most Common (benign) Causes
Fibroids
Also known as leiomyomas, fibroids are benign tumors originating from uterine tissue. They can vary greatly in size and number. They are very common and most of the time they do not cause bothersome symptoms, and go undetected. However, 1 in 4 women end up with symptoms severe enough to require treatment. Symptomatic patients may experience heavy bleeding, irregular bleeding, painful periods, as well as pelvic pressure and urinary frequency from an enlarged uterus.

Fibroids can be located inside the cavity of the uterus (submucosal), within the wall of the uterus (intramural), or on the surface of the uterus (subserosal).

Adenomyosis
Adenomyosis is an abnormal location of uterine lining cells that develops inside the uterine walls. It causes pelvic pain and heavy bleeding. Adenomyosis prevents effective uterine contractions during a period making it more painful and prolonged. Fibroids and adenomyosis may coexist in the same uterus. This may exacerbate the already severe symptoms.

Non-Surgical Treatment Options
Medical Treatment
Hormonal medications often are used to control abnormal uterine bleeding. Birth control pills can help make your periods more regular. Hormones also can be given as an injection, an implant, or through an intrauterine device (IUD) called Mirena that releases hormones. An IUD is a birth control device that is inserted in the uterus. The hormones in the IUD are released slowly and may control abnormal bleeding.

Other medications given for abnormal uterine bleeding include nonsteroidal anti-inflammatory drugs (such as ibuprofen), tranexamic acid, and antibiotics (if there is an infection).

Endometrial Ablation
Uterine Endometrial Ablation is one of the most effective options for persistent, prolonged and heavy uterine bleeding. Endometrial ablation destroys the lining of the uterus using thermal (heat) energy or a freezing technique. The procedure is ideal for patients who do not desire major surgery and are no longer interested in future pregnancy. It is an excellent alternative to hysterectomy.

Dr. Rebeles specializes in NovaSure endometrial ablation, a one-time, 5-minute procedure that can lessen or stop your heavy period altogether, without on-going pills and without hormonal side effects. For over 90% of women, menstrual bleeding is dramatically reduced or stopped. It works by removing the endometrium, or the lining of the uterus (the part that causes the bleeding), with a quick delivery of radiofrequency energy.

NovaSure endometrial ablation procedure steps and how it works:
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Your doctor slightly opens your cervix (the opening to the uterus), inserts a slender wand, and extends a triangular mesh device into the uterus
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The mesh gently expands, fitting to the size and shape of your uterus
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Precisely measured radio frequency energy is delivered through the mesh for about 90 seconds
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The mesh device is pulled back into the wand, and both are removed from the uterus.

No part of the NovaSure endometrial ablation device remains inside your body after the NovaSure procedure.
Surgical Treatment Options
Dilation and Curettage
A dilation and curettage (D&C) is an outpatient procedure designed to immediately stop severe, sometimes life-threatening bleeding, or to diagnose the cause of bleeding with a sample of tissue from the lining of your uterus (endometrium). This procedure helps diagnose uterine cancer, uterine polyps and endometrial hyperplasia — a precancerous condition in which the uterine lining becomes too thick.

Hysteroscopic Myomectomy and Polypectomy
Hysteroscopy is an outpatient minimally invasive procedure designed to remove uterine fibroids or polyps located in the uterine cavity that may be the cause of abnormal bleeding. The ultimate goal of the procedure is complete cessation of abnormal bleeding and inspection of the tissue removed to rule out the presence of cancer. This procedure is an outpatient procedure. Hysteroscopy is accomplished by inserting a long tubular camera scope called a hysteroscope through the cervix into the uterus, then inserting various instruments to remove polyps or fibroids.

Dr. Rebeles utilizes the Myosure Tissue Removal System, a hysteroscopic outpatient procedure that can eliminate fibroids or polyps without having to cut or remove any part of your uterus.

Laparoscopic (and Robotic-assisted) Myomectomy:
This procedure is a minimally invasive surgery which removes intramural and subserosal fibroids from the uterus via small abdominal incisions. They require a highly skilled surgeon specializing in minimally invasive surgery. The advantages of a laparoscopic procedure are many. Patients usually go home the same day, the recovery time is faster and less painful, and the cosmetic outcome is better. Dr. Rebeles operates through a few small abdominal incisions using either the assistance of the daVinci robot or via traditional laparoscopy.
(Please also see: Robotic-Assisted Myomectomy under Robotic Surgery )

Laparoscopic (and Robotic-assisted) Hysterectomy
A hysterectomy refers to the removal of a woman’s uterus (womb) and possibly the cervix. Hysterectomy is one of the most common surgeries in the United States, with approximately 600,000 performed annually. Dr. Rebeles operates through a few small abdominal incisions using either the assistance of the daVinci robot or via traditional laparoscopy.
  • Total (or complete) hysterectomy involves the removal of the entire uterus, but not necessarily the ovaries
  • Partial, subtotal and supracervical hysterectomy are all terms to describe removal of the part of the uterus above the cervix, which is the part of the uterus responsible for growing and shedding the endometrial (uterine) lining.
(Please also see: Robotic-Assisted Hysterectomy under Robotic Surgery )

Vaginal Hysterectomy
The uterus is removed entirely through the vagina. During a vaginal hysterectomy, the surgeon detaches the uterus from the ovaries, fallopian tubes and upper vagina, as well as from the blood vessels and connective tissue that support it. The uterus is then removed through the vagina.

Dr. Rebeles will discuss with you which type of surgery is best for you and the pros and cons of each.





































About Endometriosis Chronic Pelvic Pain
Pain in the pelvic area that lasts for 6 months or longer is called chronic pelvic pain. An estimated 15–20% of women aged 18–50 years have chronic pelvic pain that has lasted for more than 1 year.

Chronic pelvic pain in women can disrupt work, physical activity, sexual relations, sleep, or family life. It also can affect a woman’s mental and physical health.

Diagnosis and Causes
Pelvic pain can have many causes and often is hard to diagnose. It can be caused by a variety of conditions. Some of these conditions may not be related to the reproductive organs but to the urinary tract or bowel. Some women have more than one condition that might be the cause of their pain. For some women with chronic pelvic pain, no cause is found. Not finding a cause does not mean that the pain is not real. Experts agree that with pelvic pain, it is not always possible to pinpoint a specific cause. Endometriosis, fibroids, pelvic inflammatory disease, bowel and bladder conditions, and muscular and skeletal problems may all cause pelvic pain.

endometriosis
Endometriosis is a condition in which the type of tissue that forms the lining of the uterus (the endometrium) is found outside the uterus. It occurs in about one in ten women of reproductive age. Many women with endometriosis have no symptoms or only mild discomfort. Others have Endometriosis pain that is so severe that it prevents them from doing their normal activities. Endometriosis also is a leading cause of infertility.
Non-Surgical Treatment
Chronic pelvic pain that is caused by a specific condition is treated with medication or surgery. Conservative treatment should be attempted first by using a hormonal agent, if no contraindications to these medications exist. Birth control pills, the birth control implant, the birth control injection, or the hormonal intrauterine device (IUD) may be prescribed for treatment of painful periods and endometriosis. Drugs that stop hormone release also may be used to treat endometriosis. Non-steroidal anti-inflammatory medications are given as well to control pain and inflammation. Rarely, narcotic pain medications are needed and patients may be referred to a pain management provider. Some research suggests that antidepressants may be helpful in the treatment of chronic pelvic pain.

Surgical Treatment
For some problems, surgery may be done if medications do not work. Fibroids and cysts can be removed surgically. Endometriosis tissue also can be removed with a special type of laparoscopic surgery. Hysterectomy may be an option.

Laparoscopic (or Robotic-Assisted) Removal of Endometriosis
Laparoscopy, considered the gold standard for diagnosis of endometriosis, is also recognized as subsequent management when conservative therapy fails. Laparoscopic excision or laser ablation of endometriosis is the recommended approach if the patient wishes to preserve her fertility/pregnancy potential.

Uterine and pelvic innervations travel through particular ligaments called the uterosacral ligaments, which are located adjacent to the uterus and are usually accessible during laparoscopic surgery. Sometimes LUNA (Laparoscopic Uterosacral Nerve Ablation) is performed and involves resection of the uterosacral ligaments and nerves.

If pelvic adhesions are severe and involve or invade the bowel and/or bladder, additional concomitant procedures may be required. Sometimes assistance from a urologist or colorectal surgeon is requested.
(Please also see: Robotic-Assisted Removal of Endometriosis under Robotic Surgery )

Laparoscopic (or Robotic-Assisted) Hysterectomy
This option is offered as a last resort for treatment of chronic pelvic pain, or for patients who desire definitive management of pelvic pain due to endometriosis. This may be performed with or without removal of the ovaries and Fallopian tubes.
(Please also see: Robotic-Assisted Hysterectomy under Robotic Surgery )







































About Ovarian Cysts and Benign Tumors
An ovarian cyst is a sac or pouch filled with fluid or other tissue that forms on the ovary. It is normal for a small cyst to develop on the ovaries. In most cases, cysts are harmless and go away on their own. In other cases, they may cause problems and need treatment.

In the US, a woman has a lifetime risk of 5-10% of undergoing surgery for a suspected ovarian cyst or tumor. Out of this group, 13-21% of women are diagnosed with ovarian cancer. Thus most ovarian masses are benign. The most common ovarian mass in a menstruating woman is a functional simple ovarian cyst that resolves by her next menstrual cycle. In a post-menopausal woman, the most common ovarian mass is a non-cancerous cystadenoma. The goal of evaluation is to rule out cancer. Management decisions are often based on patient’s age, family history, patient’s symptoms, imaging studies, and blood testing results.

Non-Surgical Treatment
Masses with a low risk of cancer are often managed conservatively without surgery unless the patient is having pelvic pain or other associated symptoms. If your cyst is not causing any symptoms, the cyst may be monitored for 2-3 months and checked later to see whether it has changed in size. Most functional cysts go away on their own after one or two menstrual cycles.

If you are past menopause and have concerns about cancer, your health care provider may recommend regular ultrasound exams to monitor your condition. If the appearance of your cyst changes or if it gets bigger, treatment may be needed. Usually if cancer is expected, evaluation and surgery are performed by a gynecologic oncologist.

Surgical Treatment
Laparoscopic (or Robotic-assisted) Ovarian Cystectomy
Benign cysts can be removed using laparoscopic surgery via a few small incisions on the abdomen, usually on an outpatient basis (you leave the hospital the same day). Normal activity can be resumed in a week or two.

Ovarian cysts usually do not require surgery, with some exceptions:

  1. When they do not go away after several weeks
  2. When they continue to grow and/or are very large
  3. When cancer is suspected
  4. When they cause severe pain
Dr. Rebeles performs the vast majority of cases laparoscopically or using the assistance of the daVinci robot. Cystectomy is the surgical removal of a cyst. Most ovarian cysts are benign growths known by names such as “dermoid cysts” or “cystadenomas”. Often the cyst can be removed leaving the ovary intact, but occasionally the entire ovary must come out, for example, if the cyst is very large and has destroyed the ovary.
(Please also see: Robotic-Assisted Ovarian Cystectomy under Robotic Surgery )







































About Urinary Incontinence
Leakage of urine is called urinary incontinence. It is a common problem in women. Some women occasionally leak small amounts of urine. At other times, leakage of urine is frequent or severe. Often, women with this condition are too embarrassed to tell their health care providers about their symptoms. However, with proper diagnosis, urinary incontinence can most often be treated. There are different types of urinary incontinence.

Types of Urinary Incontinence
The most common types in women include stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI) in which a patient has both SUI and UUI. Stress Urinary Incontinence (SUI) is defined as urinary leakage associated with laughing, coughing, sneezing, jumping, or physical activity. Urge Urinary Incontinence (UUI) is defined as urinary leakage associated with a feeling of urge to urinate. Many times patient’s leak when they are not able to reach the bathroom quickly. Overactive bladder (OAB) is a common condition affecting 1 in 6 adults. With OAB, the bladder muscle squeezes too often, causing frequent, strong sudden urges to go. As a result, patients experience urinary urgency and frequency and sometimes they can leak urine if they are not able to reach the bathroom quickly.

Non-Surgical Treatment
Overactive Bladder (OAB) with or without Urge Urinary Incontinence (UUI) caused by involuntary bladder wall contractions that may happen randomly and at the least convenient times and locations. The first line of treatment consists of a daily medication. These medications effectively “calm” the bladder wall and decrease urinary frequency and leakage.

Patients afflicted with Mixed Urinary Incontinence (MUI) have both SUI and UUI symptoms. Dr. Rebeles treats both conditions separately as described.

Surgical Treatments
Surgical correction is the only effective treatment to repair the hypermobility of the urethra and to get rid of SUI. Dr. Rebeles performs suburethral sling procedures to eliminate SUI. These procedures involve placing a permanent polypropylene mesh under the bladder neck to support it. The incision sites are very small and heal quickly. The procedure is done in an outpatient surgery center, usually takes about 15 minutes, and can be done either under general or regional anesthesia. Recovery time is short and usually patients can return to work in 1-3 days.









































About Pelvic Organ Prolapse
Pelvic organ prolapse is caused by a weakening of the normal support provided by muscles and tissues of the pelvic floor. The main cause of pelvic organ prolapse is pregnancy and childbirth, especially vaginal childbirth. Other factors include prior pelvic surgery, menopause, and aging. Activities or conditions that increase pressure in the abdomen, such as a long-lasting cough, obesity, or straining with bowel movements due to constipation, can play a role in pelvic organ prolapse. Prolapse also runs in families.

Pelvic organ prolapse usually involves more than one organ. The organs that can be affected include the following:
  • Uterus
  • Top of the vagina in women who have had a hysterectomy (the vaginal vault)
  • Front (anterior) wall of the vagina (usually with the bladder, which is called a cystocele)
  • Back (posterior) wall of the vagina (usually with the rectum, which is called a rectocele)
  • The pouch between the rectum and back wall of the uterus (usually with a part of the small intestine, which is called an enterocele)
Diagnosis
In severe prolapse, the woman can see or feel a bulge of tissue at or past the vaginal opening. Most women have mild prolapse - the organs drop down only slightly and do not protrude from the opening of the vagina - and do not have any signs or symptoms. Some women with mild prolapse and women with severe prolapse do have symptoms, which can include the following:
  • Feeling of fullness or heaviness in the pelvic region
  • Pulling or aching feeling in the lower abdomen or pelvis
  • Painful or uncomfortable sex
  • Difficulty urinating or having a bowel movement
Non-Surgical Treament
If you do not have any symptoms or if your symptoms are mild, you do not need any special follow-up or treatment beyond having regular checkups. If you have symptoms, prolapse may be treated with or without surgery.

Nonsurgical treatment options usually are tried first. Often the first nonsurgical option tried is a pessary. This device is inserted into the vagina to support the pelvic organs. There are many types of pessaries available. A health care provider can help you find the right pessary that fits comfortably. Targeting specific symptoms may be another option. For example, bowel problems can be addressed with behavioral changes, dietary changes (such as adding more fiber to the diet), and stool softeners. Kegel exercises may be recommended in addition to symptom-related treatment to help strengthen the pelvic floor. Weight loss can decrease pressure in the abdomen and help improve overall health.

Surgical Treatment Options
When symptoms are severe and disrupt a patient’s life and if nonsurgical treatment options have not helped, surgery is an option. The following factors should be considered when deciding whether to have surgery: age, child-bearing plans and health conditions.

There is no guarantee that any treatment—including pelvic prolapse surgery—will relieve all of your symptoms. Pelvic prolapse of the same site can come back after surgery. Prolapse also can occur at a new site after surgery. Depending on whether you have symptoms, additional treatment with nonsurgical options, such as a pessary, or surgery may be needed.

Laparoscopic (or Robotic-assisted) Uterosacral Ligament Suspension
A uterosacral ligament suspension involves suturing the uterosacral ligament to the top portion of the vagina. This procedure is normally performed by placing two sutures through each uterosacral ligament and then through the cuff or apex of the vagina. The suture is tied to support the cuff or apex to the uterosacral ligaments.

Laparoscopic Suspension
By performing the uterosacral ligament suspension minimally invasively, Dr. Rebeles is able to reposition the vagina to its anatomic position in a minimally invasive manner. Most surgeons perform this procedure through a large incision or through the vagina. A large abdominal incision (laparotomy) will contribute to a longer recovery time. If performed vaginally there is often difficulty identifying the uterosacral ligaments appropriately. The laparoscopic approach allows Dr. Rebeles to define the ligaments readily and also identify key anatomic structures. (Please also see: Robotic Uterosacral Ligament Suspension under Robotic Surgery )


Laparoscopic (or Robotic-Assisted) Sacrocolpopexy
Laparoscopic Sacrocolpopexy
This is a procedure to correct prolapse of the vaginal vault (top of the vagina) in women who have had a previous hysterectomy. The operation is designed to restore the vagina to its normal position and function.

Sacrocolpopexy is traditionally performed through an abdominal incision which requires a prolonged recovery time. Dr. Rebeles is trained to perform this procedure via a minimally invasive approach.
Completed Sacrocolpopexy
The vagina is first freed from the bladder at the front and the rectum at the back. A graft made of permanent synthetic mesh is used to cover the front and the back surfaces of the vagina. The mesh is then attached to the sacrum (tail bone) as shown. The mesh is then covered by a layer of tissue called the peritoneum which lines the abdominal cavity; this prevents the bowel from getting stuck to the mesh. (Please also see: Robotic-Assisted Sacrocolpopexy under Robotic Surgery )









































Ovarian cancer is the most lethal gynecologic malignancy. This is because we lack a reliable screening test to detect early-stage ovarian cancer and most women have advanced disease when the diagnosis is discovered. The average age at diagnosis is 63 years old. Lifelong risk of developing a nonhereditary ovarian cancer is 1.4% or about 1 in 70 (as compared to 1 in 7 for breast cancer).

Hereditary breast and ovarian cancer syndrome is an inherited cancer-susceptibility syndrome. The hallmarks of this syndrome are multiple family members with breast and/or ovarian cancer and early age of breast cancer onset. In patients at high risk for hereditary breast and ovarian cancer syndrome, genetic testing for BRCA1 and BRCA2 germline mutations is available. The BRCA gene testing can be performed from a small blood or saliva sample collected in the office. The result of this test can help physicians precisely identify who is at substantial risk of breast and ovarian cancer.

Approximately 10% of cases of ovarian cancer and 3-5% of cases of breast cancer are due to these 2 mutations. Options for patients, who test positive for BRCA1 or BRCA2 mutation, include surveillance, chemoprevention, and surgery. Available ovarian cancer screening tests and procedures are very limited and there is no evidence that screening alone has reduced the mortality or improved survival associated with hereditary breast and ovarian cancer syndrome.

Consensus groups have recommended periodic screening with CA 125 and transvaginal ultrasonography, beginning between 30-35 years old or 5-10 years earlier than the earliest age of first diagnosis of ovarian cancer in the family (but not earlier than 21 years old). Given the limitations of current ovarian cancer screening approaches, preventive/prophylactic removal of ovaries and fallopian tubes (bilateral salpingo-oophorectomy, or BSO) should be offered to patients who test positive for BRCA1 or BRCA1 by the age of 40 years old or after childbearing is completed. This can decrease the threat of ovarian, fallopian tube and primary peritoneal cancers by approximately 85-90% and also has been shown to reduce overall mortality in HBOC syndrome patients.

Laparoscopic Risk-Reducing Salpingo-oophorectomy
Traditional surgery to prophylactically remove the ovaries and tubes involves a large incision in the abdomen. This results in significant pain as well as inpatient stay of 2-3 days and additional recovery of 4-6 weeks. The best approach is to perform minimally invasive surgery via a laparoscopic (or robotic) bilateral salpingo-oophrectomy (BSO). The advantages of a laparoscopic approach include better visualization, decreased pain, much shorter recovery time and better cosmetic outcome. The procedure is performed in an outpatient surgery center under general anesthesia and patients go home the same day.

Robotic Risk-Reducing Salpingo-oophorectomy
Dr. Rebeles prefers the robotic approach to risk-reducing salpingo-oophorectomy because it allows for better surgical precision, including increased visualization, a high-definition, 3-dimensional view of pelvic anatomy, and less blood loss. The recovery time is essentially identical to its laparoscopic counterpart.

Performing risk–reducing salpingo–oophorectomy in women at an increased risk of ovarian cancer necessitates complete removal of the ovaries and fallopian tubes. Risk–reducing salpingo–oophorectomy for these women should include careful inspection of the peritoneal cavity, pelvic washings, removal of the fallopian tubes, and ligation of the ovarian vessels at the pelvic brim. If hysterectomy is not performed, care must be taken to completely remove the fallopian tubes.

Dr. Rebeles is fortunate to have completed her minimally invasive gynecologic surgical fellowship under the guidance of two of the Pacific Northwest’s leading Gynecologic Oncologists, Dr. Howard Muntz and Dr. Kathryn McGonigle of Women’s Cancer Care of Seattle. Although Dr. Rebeles only performs surgery for benign gynecologic conditions, she is trained in how to adequately perform risk-reducing salpingo-oophorectomy in patients at high risk of ovarian cancer, and does so always in consultation with a Gynecologic Oncologist.







































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