Owen Owens MD MRCOG MRCPI - About womens gynecological health issues
Some women will develop irregular periods between 3 and 5 years before they go through the menopause. The periods may occur more frequently every 3 weeks instead or 4 weeks and last longer. Often no clear reason is found but investigations include a full blood count, blood tests for the thyroid gland and also a pelvic scan looking at the uterus and ovaries which is performed both abdominally and vaginally. Women who develop spotting between periods usually on 3 consecutive months (intermenstrual bleeding or IMB) should also be investigated. The main thing to exclude on a pelvic scan is a polyp.
Pelvic pain is a common problem in women and can occur at certain times in the month. If the pain occurs during sexual intercourse on a frequent basis then it is advised that a woman should see her GP with a view to ascertaining the cause. Often a pelvic or vaginal exam is performed by the GP and an ultrasound scan is arranged to determine the size of the uterus and also to check that the ovaries are normal. Sometimes a laparoscopy is performed to determine the cause of the pain. Endometriosis also needs to be excluded.
Endometriosis is a condition where tissue like the lining of the womb can affect the ovaries or the support ligaments of the uterus. Rarely it can affect the bowel and bladder. Endometriosis can cause the ovaries to enlarge and can cause minor bleeding within the ovaries which give rise to pain at any time or at or after a period. Endometriosis on the ligaments that support the uterus can cause scarring on these ligaments and can lead to pain with intercourse. The cause of endometriosis is beyond the scope of this paragraph.
Prolapse generally means that something can drop. This can be associated with weakness of the front wall of the vagina where the bladder can bulge slightly into the vagina. This happens when the support structures or fascia weaken as a result of child birth. This condition is called a cystocoele. If the back wall of the vagina weakens it is called a rectocoele and if the uterus prolapses that means the cervix which is the neck of the womb descents to the vaginal entrance. The treatment includes a ring pessary in some women, and surgery for the cystocoele and rectocoele. When the uterus and cervix prolapses then surgery may be required, which can necessitate removing the uterus and cervix vaginally or doing a special operation to elevate the uterus and cervix. Again the technical descriptions of surgery is beyond the scope of this paragraph.
Laparoscopy is performed under a general anaesthetic where a small incision is made either within the umbiliacus (tummy button) or just below. It allows the surgeon to assess the pelvic organs which is the uterus, fallopian tubes and ovaries. The surgeon can check that the fallopian tubes are patent (open), that there is no endometriosis or any other signs of gynaecological infection. If there are ovarian cysts it is possible to surgically remove the cysts but keep the ovaries and all the surgery is done by usually 2 other key hole incisions. Laparoscopic surgery is either day case surgery or an overnight stay.
Again using very small instruments it is possible to look into the uterus (womb) either under local anaesthetic or a general anaesthetic. The instrument (hysteroscope) allows the surgeon to take biopsies (samples) of tissue, remove polyps, or even treat women with heavy periods (Novasure or endometrial ablation). Fibroids lying within the uterus can be removed. All these procedure can be done as day cases.
Fibroids are very common and arise either within the muscle of the uterus (intramural fibroids), grow into the lining of the uterine cavity (sub-mucosal) or grow on the outside of the uterine muscle (serosal). The management of fibroids depends on the size and whether they are contributing to heavy periods or occasionally infertility problems. Medical treatment for fibroids can be used and this is usually a monthly injection. However on stopping treatment the fibroids can grow back so long term medical treatment has little to offer. Surgery is required for women who are symptomatic and fibroids can be removed either by key hole or open surgery.
Hormone Replacement Therapy (HRT)
HRT is required for women who either go through an early menopause or have there ovaries removed for other reasons. If the uterus is removed along with the ovaries then HRT is usually given in the form of oestrogen only. If the uterus is present then a combination of oestrogen and progesterone is given either in the same dose every day or in a different regime where progesterone is added in for 10 – 12 days at the end of each cycle. HRT can be used as a Gel, a tablet or a combination of patches. The dose varies with each individual. Implants are less commonly used nowadays as the dose is high and they have to be replaced very 6 months. Women who take HRT are usually warned that there is a slightly increased risk of a clot happening in the leg (DVT) and if there is any family history of a DVT then the women needs to be screened for any inherited disorders. The risk of breast cancer in women on HRT is relatively low but every women who seeks HRT an accurate history should be taken to determine any risk factors.
Colposcopy for abnormal smears
Women with abnormal smears are now referred directly from the laboratory that reads the smear to the colposcopy clinic. Women can be seen in their NHS clinics or privately. The abnormal smear can happen as a result of a virus infection called human papilloma virus (HPV) which can be passed through sexual intercourse. HPV can in turn damage the normal cervical cells and cause pre-cancer of the cervix know as cervical inta-epithelial neoplasia (CIN and CIN is graded as 1 for minor, 2 for moderate and 3 for severe).The colposcope is a magnifying instrument which allows the gynaecologist to examine the cervix in detail. The procedure takes 10 – 15 minutes and a solution is applied to the cervix called acetic acid. This allows the cervix to stain white and then allows the gynaeologist to determine the severity of the abnormality and to take a sample of tissue (biopsy) to be examined in the laboratory by a pathologist or treat the women’s cervix using a small tissue loop performed under local anaesthetic injected into the cervix.
The vulva is the tissue that lies outside the vagina. On either side of the vagina the vulva is divided into the labia minor which come down from the clitoris or the labia major (the main part of the vulva). Conditions that can occur are cysts at the vaginal entrance called Bartholin’s cysts. Older women can develop a condition called lichen sclerosus where the skin can harden on the vulva and make it scarred and sore. Less commonly is a condition called vulval intra-epithelial neoplasia (VIN) which is a pre-cancerous condition and can be associated with earlier pre-cancer of the cervix (CIN). VIN is removed surgically. Other benign cysts can occur on the vulva. Rarely cancer of the vulva can happen and any women with a persistent growth on the vulva should have this assessed for piece of mind. In younger women a condition can occur where the entrance of the vagina can tear with intercourse. This requires specialist treatment and is usually medical.
Hysterectomy literally means removing the uterus either vaginally, abdominally or by key hole surgery. Hysterectomy is performed for benign conditions such as fibroids or a condition called adenomyosis (where bleeding occurs within the muscle of the uterus) and adenomyosis can be confused with fibroids. Sometimes an MRI scan of the pelvis is required to make a diagnosis of adenomyosis or to exclude fibroids. Hysterectomy may be offered to women who have not responder to medical treatment for their periods or who have failed procedure such as a Novasure operation or endometrial ablation by some other technique. In older women who may develop cancer of the lining of the womb then a hysterectomy is offered by open or key hole surgery depending on a number of factors which is beyond the scope of this paragraph. Some women with intractable endometriosis may consider a hysterectomy. In younger women who are undergoing a hysterectomy they should be offered the prospect of keeping their cervix. A vagninal hysterectomy is offered to women for benign conditions provided the uterus is not too big and the uterus is removed through the vagina.
Post menopausal bleeding
Post menopausal bleeding is bleeding from the genital tract after a women has stopped having periods. Generally the time interval taken is 1 year after the last period but some people take 6 months. The main part of the examination is to exclude an early cervical cancer which ideally should not occur if prior to the event the women has being having regular cervical smears. The other possibility is to exclude polyps in the uterus or an early cancer. There are other rare causes which include cancer of the vagina, fallopian tube or ovary. The management includes a gentle pelvic examination along with an ultrasound scan of the pelvis to assess the thickness of the lining of the womb (the thickness should be 5 mm or less) and also a sample may be taken from the uterus using a fine plastic catheter called a pipelle. The ovaries are also assessed at the same time.
Gynaecological Cancer Surgery
This is specialist surgery performed for women who may have cancer of the vulva, less commonly the vagina, the cervix, uterus, fallopian tubes and ovaries. As the surgery is specialized each women’s case had to be discussed with specialist teams to make sure the correct treatment is offered. In almost every case of the above conditions either an MRI or CT scan would be performed to assess the volume or amount of disease, assess the lymph nodes and other structures in the chest, abdomen and pelvis.
Spire Harpenden Hospital, Ambrose Lane, Harpenden, AL5 4BP Tel: 0800 585112
Spire Bushey Hospital, Heathbourne Road, Bushey Heath, WD23 1RD Tel: 01582 760045
Cobham Private Clinic, Luton & Dunstable NHS Trust, Lewsey Rd, Luton, LU4 0DZ Tel: 01582 718193
Luton & Dunstable NHS Trust, Lewsey Rd, Luton, LU4 0DZ Tel: 01582 497459