Cervical disease is based on the study of the cervix for the diagnosis of preinvasive lesions and cervical cancer. The main screening method is the Pap test, which is done on all patients during gynaecological exams.
Since 1967 these cervical abnormalities are classified (Richart) into three grades of cervical intraepithelial neoplasia (CIN) according to the severity of the abnormality. According to the National Cancer Institute in Bethesda, they are currently classified as high- and low-grade squamous intraepithelial lesions (SIL).
These changes involve a battery of tests and/or treatments that depend on the degree and its association with high-risk HPV.
A biopsy for precise diagnosis will be required if the Pap test reveals any abnormality. Once the abnormality is confirmed it will be necessary to determine if the patient has HPV. Once we have all the results we will assess the patient’s risk factors and the most appropriate treatment will be developed:
- Regular pelvic exams
- Pap tests
- HPV vaccine
It is important for patients with cervical abnormalities to undergo regular gynaecological exams to ensure that the disease has not progressed.
The Human Papillomavirus (HPV) is one of the most common sexual transmitted infections; as many as 75% of sexually active people will have an HPV infection some time in their lives, especially young patients in the 15-25 age group. HPV infection is the main factor in nearly all cases of cervical cancer. Most HPV infections in young females are temporary and have little long-term significance; going away without causing any symptoms. 70% of infections disappear within a year and 90% in two years. But if the infection persists (between 5 and 10 percent of infected women) there is a risk of developing precancerous lesions in the cervix, which can progress to invasive cervical cancer. This process usually takes between 15 and 20 years. This provides a long period of time in which to diagnose and treat precancerous lesions (called SIL, CIN or dysplasia), with a high cure rate. There are many subtypes of HPV, some can cause common warts or genital warts, while others can cause subclinical infections that can lead to cervical, vulvar, vaginal and anal cancer in women. Most people infected with HPV never know they have the virus. All HPV is transmitted by skin to skin contact and the lesions are diagnosed by the Pap and/or HPV screening test. The recent release of HPV vaccines (Cervarix® and Gardasil®, which prevents infection in people with high-risk HPV (mainly types 16 and 18) that cause 70% of cervical cancer) has resulted in a drastic reduction of invasive cervical cancer. It is important that women continue with Pap tests even after receiving the vaccine, as current vaccines do not protect women against all HPV types that cause cervical cancer.
- Benign tumour that grows within the muscle tissue in the wall of the uterus.
- Very common tumours in women of childbearing age.
- No one knows what causes uterine fibroids, but their growth seems to depend on oestrogen, the female hormone; therefore, they usually grow during pregnancy and the reproductive stage and decrease with menopause.
- Clinical manifestations of fibroids depend on their location and size.
There are three main types of fibroids, according to their location in the uterus:
- Submucosal: grow into the uterine cavity.
- Subserosal: grow from the outer lining of the uterus into the pelvic cavity.
- Intramural: located inside the uterine wall.
- Pendunculated: attached to the outer or inner surface of the uterus by a stalk or peduncle.
Many fibroids are asymptomatic and can go unnoticed. In this case, they are usually diagnosed during routine gynaecological exams. However, the most common symptoms of fibroids includes:
- Changes in bleeding: irregular bleeding between cycles or prolonged, heavy menstruation
- Pelvic or lower abdomen pain
- Problems urinating (pressure on the bladder): difficulty starting urination, frequent urination
- Painful intercourse
- Intestinal discomfort: constipation (rectal compression)
Fibroids are diagnosed by a history of symptoms and a thorough gynaecological exam.
The size, shape and consistency of the uterus as well as the number of fibroids can be determined through abdominal palpations and a pelvic exam. Furthermore, additional tests are often ordered to map and measure these fibroids. The most common tests are:
- Vaginal ultrasound: ultrasound imaging test that can detect the number, location and size of fibroids.
- MRI scan: the most precise test. Indicated for preoperative evaluation.
- Hysteroscopy: examination of the uterine cavity using a camera that makes it possible to assess the size and number of submucosal fibroids.
Fibroids may reduce a woman’s fertility.
In case of pregnancy, fibroids often grow larger but do not affect the development of the foetus.
However, complications may develop:
- Premature birth
- Abdominal pain due to decreased blood flow to the fibroid
- Caesarean if fibroid is blocking the birth canal or alters the position of the foetus in utero
- Changes in uterine contractility
- Heavy postpartum bleeding
There are multiple treatments for fibroids.
The gynaecologist will determine the most appropriate treatment options for each case.
If the patient is asymptomatic, only check-ups will be required.
We emphasise two treatment groups:
- GnRH analogues: slows the ovary’s hormone production and makes it possible to shrink the fibroids. Intramuscular or subcutaneous dosage. Temporary use (3-4 months).
- Ulipristal acetate: works by modifying progesterone (female sex hormone) receptors. Its purpose is to reduce the size of fibroid prior to surgery, stopping the bleeding caused by the fibroid and improving anaemia. Temporary use (3 months).
- Myomectomy: fibroid/myoma removal that leaves the uterus in place. Preferred treatment for women who want to remain fertile. Surgery can be performed via hysteroscopy, laparoscopic or abdominally, depending on the location, size and number of fibroids.
- Hysterectomy: the uterus is removed through a cut in the vagina, abdomen, or using a laparoscope.
- Fibroid embolization: occlusion of blood vessels supplying the fibroids, causing them to die and thus shrink in size.
Adnexal masses (ovary or fallopian) are a common gynaecological problem. The diverse types of adnexal tumours (functional, inflammatory, endometriotic, malignant) and the different clinical approach that each requires (observation, medical treatment, surgical treatment) explains the importance of its accurate evaluation. A complete medical history and ultrasound are critical in determining the nature of the lesion.
There are two main categories:
- Simple functional cyst: sac filled with fluid that forms inside the ovary or on its surface. A follicle (where the egg develops) grows in the ovary every menstrual cycle. Most months, an egg is released from the follicle, which is called ovulation. If the follicle fails to break open and release an egg, the fluid stays in the follicle and forms a cyst, which is called a follicular cyst. Treatment is generally unnecessary and they usually disappear on their own in 2-3 months.
- Haemorrhagic cyst: functional cyst that contains or releases blood. While fairly uncommon, if the haemorrhagic cyst ruptures it sheds blood in the pelvis, causing pain in the lower abdomen. Haemorrhagic cysts are common entity that usually do not require treatment. Laparoscopic resection and coagulation will be performed if the cyst ruptures and releases large amount of blood in the pelvis, confirmed by ultrasound and blood tests.
- Endometrioma: originate from endometrial tissue. It is filled with a thick, dense, brownish fluid and the capsule is fibrous and thick.
- Dermoid cyst: originate from totipotential germ cells that can grow different types of tissue. As a result, dermoid cysts usually contain fat, teeth, hair and bits of bone.
Treating benign ovarian cysts does not always require surgery. A surgical approach should be taken when there are changes in the morphology of the cyst, risk of breakage or rupture, torsion, symptoms of persistent pain or cysts measuring 4-10 cm in women of childbearing age with associated pain who want to become pregnant.
Currently, laparoscopic cystectomy is the technique of choice in dealing with benign adnexal tumours as the technique is associated with less postoperative morbidity, earlier recovery and lower overall cost.
- Ectopic pregnancy: dilated fallopian tube as the result of embryo implantation. If the tube bursts it causes sharp abdominal pain and hypotension associated with pelvic bleeding that requires surgical treatment, removing ectopic tissue using laparoscopy
- Hydrosalpinx: fallopian tube dilated with fluid.
- Tubo-ovarian abscesses: pus is confined in the fallopian tube (PID).
Ovarian or tubal cancer. Ovarian cancer is the third most frequent cancer in the female genital tract, but it is the leading cause of death from gynaecologic cancers. There are two age groups in which the incidence of this disease spikes: the first is among women of childbearing age (20 to 30 years old), the other is the 50 to 70 age group. These two groups have different tumour and anatomopathological features. Most patients are asymptomatic or have a very vague symptoms (nausea, indigestion, abdominal bloating and vague pelvic pain).
Early diagnosis of ovarian cancer is difficult and is has usually already grown to an advanced stage when diagnosed. Therefore, it is important that gynaecological ultrasounds are carefully performed during annual pelvic exams as there are some warning signs of malignancy that include: bilateral cysts, hard or irregular mass, adherence to deep tissue, ascites, pathological Doppler and heterogeneous.
Ovarian cancer treatment is multidisciplinary and surgery has a dual objective: therapeutically, to remove as much of the tumour as possible so that only a residual tumour with a mass of less than 2 cm remains, and diagnostically to obtain samples of different tissues for analysis in order to diagnose and determine the stage of the tumour. The Department of Oncology will make an assessment based on all of this information.
Endometriosis is a chronic disease that involves the appearance and growth of endometrial tissue outside the uterus (original location), particularly in the pelvic cavity and ovaries, vagina, rectum, bladder, intestine or peritoneum. It appears less frequently outside the abdomen, lungs and even the brain. Endometriosis can affect any woman of childbearing age, but sometimes can last until after menopause. Initial lesions have a reddish appearance and eventually become black implants which can even form chocolate-like cysts inside. They can cause adhesions or flanges of the pelvic organs that limit their normal functioning and cause pain.
The cause of endometriosis is unknown or uncertain. One theory is that menstrual tissue, rather than flowing out of the cervix through menstruation, returns to the abdomen by flowing backward through the fallopian tubes (called retrograde flow).
It should be noted that not all women who have retrograde flow have endometriosis. Another theory suggests that there are cells in the peritoneum that become endometrial. The endometrial tissue that escapes the uterus ends up surrounded by epithelium and forming cysts called endometriomas. Other researchers have observed that oestrogen promote the growth of the disease. In some cases, these hormones stimulate the body’s cells to generate endometriosis.
Symptoms of endometriosis can vary
- Asymptomatic: 50% of cases.
- Pain: most common symptom of endometriosis, likely caused by lesions and adhesions. Pain increases during menstruation and sexual intercourse, but pain can also be felt in the rectum, bladder, back and limbs.
- Hypermenorrhoea: very heavy menstrual bleeding.
- Sterility: difficulty or inability to become pregnant.
- Intestinal disorders: diarrhoea, constipation, painful bowel movements and proctalgia.
- Amenorrhea: absence of menstruation due to internal bleeding into the abdominal cavity.
The diagnosis of endometriosis is difficult and often requires one or more tests, such as:
- Pelvic exam: implants are rarely palpable.
- Pelvic ultrasound: to detect lesions caused by endometriosis, such as cysts or organ retraction, although endometriosis frequently generates very small lesions that cannot be detected with this method.
- MRI: in selected cases only.
- Laparoscopy: this is the test that can diagnose endometriosis with the most certainty. It involves inserting a camera through the navel and inflating the abdomen with gas in order to directly observe the abdominal cavity and pelvic organs.
It should be said from the outset that endometriosis cannot be cured; only the symptoms can be treated. The type of treatment depends on age, severity of symptoms, severity of illness, desire to get pregnant or not, etc.
If symptoms are mild they can be controlled with paracetamol, ibuprofen or naproxen, accompanied by exercise and relaxation techniques. Prescription painkillers (opioids) may be required for more severe symptoms.
These drugs can prevent endometriosis from worsening. They can be administered as pills, a nasal spray or intranasal injections. Only indicated for women who do not wish to become pregnant.
- Birth control pills: taken continuously for 6-9 months, they relieve most symptoms.
- Progesterone pills or injections: helps reduce the size of the implants.
- Gonadotropin agonists: prevent the ovaries from producing oestrogen, causing a state similar to menopause and slowing the disease. But they can cause side effects like hot flushes, vaginal dryness, mood swings and osteoporosis.
Indicated in cases of severe pain that does not improve with other treatments.
- Laparoscopy: can be used to both diagnose and remove implants and scar tissue.
- Laparotomy: also removes implants and scar tissue but with a larger incision, so recovery is slower.
- Hysterectomy with bilateral salpingo-oophorectomy (removal of the uterus, tubes and ovaries) provides the best chance of cure.
Inflammation caused by an infection of the upper genital tract (endometrium, myometrium, ovaries and fallopian tubes). The disease is usually transmitted via a polymicrobial infection of the cervix or vagina.
Risk factors for the disease are:
- Sexually transmitted infection
- Previous history of PID
- Untreated sexual partner
- Uterine instrumentation (for example, curettage)
Women of childbearing age who experience sudden pelvic pain should have PID ruled out. Symptoms vary (abdominal pain, fever, changes in vaginal discharge, bleeding, pain with sexual intercourse, burning during urination, etc.) with little relationship between the severity of the symptoms and the degree of inflammation.
Several complementary tests are helpful to diagnose PID:
- Blood work (signs of infection)
- Vaginal, cervix, urethra, endometrium swabs are taken to look for infecting bacteria. Remove IUD if used.
- Vaginal ultrasound: to detect distended fallopian tubes, pelvic mass
- Laparoscopy: if there are diagnostic uncertainties or an antibiotic treatment fails
Pelvic inflammatory disease is treated by combinations of a wide range of oral or intravenous antibiotics. Surgical treatment is reserved for severe infections that endanger the patient’s life, broken fallopian-ovarian abscesses, pelvic abscesses, symptomatic persistent abscesses and lack of response to medical treatment. Surgery will always be individualised and conserve as much of the tissue or organ as possible. The most important sequelae after PID are risks of ectopic pregnancy (tubal occlusion), chronic pelvic pain, pain during sexual intercourse and infertility.