Endometriosis
Ectopic occurrence of
endometrial tissue, frequently forming cysts containing altered blood.
Aetiology
Often unknown
Possibilities include
Implantation due to
retrograde menstruation
Metaplasia of coelomic
derivatives (pelvic peritoneum, some ovarian epithelium and Mullerian ducts are
derived from the same embryological source)
Embolism of
endometrial tissue in pelvic veins or lymphatics
Pathophysiology
The endometreum is
the inside lining of the uterus
Endometrial deposits
may be found in various parts of the body
Most common sites are
the ovary and pelvis
Endometrial deposits
can range from pin head size to larger cysts filled with altered blood - termed
chocolate cysts
The ectopic endometrial
tissue bleeds during menstruation due to systemic hormonal influences
Blood can cause a
fibrous reaction resulting in stricture formation, e.g. in the bowel
Clinical
features
Very variable and
unrelated to the extent of the disease
Infertility
Menorrhagia
Deep seated
dyspareunia
Pelvic pain before
and during period
Congestive
dysmenorrhoea, (secondary dysmenorrhoea caused by pelvic congestion secondary
to increased blood supply secondary to pelvic disease)
Diagnosis is
confirmed by laparoscopy
Management
Hormonal therapy - to
induce pseudo pregnancy e.g. continuos progesterone therapy
Conservative surgery
- e.g. removal or cortary of small ectopic areas of endometreum and removal of
cysts
Radical surgery - in
older women after reproduction
Complications
Rupture of a cyst can
cause acute peritonism
Fixation of uterus
Other adhesions
Pain
Pelvic inflammatory disease
Acute or chronic
inflammation in the pelvic cavity, particularly, suppurative lesions of the upper
female genital tract; e.g., salpingitis
A broad term to
describe infection involving the tubes, ovaries and parametrium, (covering of
the pelvic floor).
Aetiology
Ascending infection
through the genital tract
Direct due to trauma
delivery or abortion
Blood borne e.g. TB
Transperitoneal
infection e.g. from appendicitis or diverticulitis
Pathophysiology
Inflammation caused
by infection
May be acute or
chronic
Other pelvic
structures eg. Gut may be involved as a result of adhesions
Acute salpingitis
Fallopian tubes -
congested, oedematous, infiltrated by neutrophils
Collection of pus in
the tubes
Pus may leak into
peritoneal cavity ------ acute pelvic peritonitis
Pelvic abscess may
develop in the pouch of
Exudate collects in
the tubes leading to adhesions
Clinical
features
Acute lower abdominal
pain and fever Pain
usually bilateral
Possible vaginal
discharge and deep dyspareunia Lower
abdominal rebound tenderness
Diagnosis may be
confirmed by laparoscopy
Complications
Adhesions in the
tubes Rupture
of masses causing generalised peritonitis
Management
High doses of
antibiotics Analgesia Bed
rest
Chronic PID
Low grade infection
and effects of fibrous tissue causing adhesions
Acute exacerbations
may occur
Persistent vaginal
discharge
Deep dyspareunia Menorrhagia
Treat acute
exacerbations conservatively Pelvic
clearance may be performed
Benign
tumours of the uterus
Polyps
Pathophysiology
Composed of fibrous
tissue Often
covered in functional endometrium
Clinical features
Irregular bleeding
and menorrhagia Sometimes
colicky pain
Management
Cervical dilation and
uterine curettage
Fibroids
Pathophysiology
Uterine myomas Tumours
derived from smooth muscle
Benign tumours Single
or multiple
Small to very big
Aetiology
Unknown
Clinical features
May be asymptomatic Menorrhagia
Colicky pain Pressure
symptoms
Complications of
pregnancy
Management
Surgical excision to
preserve function but hysterectomy is best
Malignant
tumours of the uterus
Endometrial carcinoma
Factors
Obesity Nulliparous Late
menopause
Diabetes mellitus Exogenous
oestrogen
Pathology
Endometrial
adenocarcinoma
Stages
Features
Post menopausal
bleeding
Premenopausaly -
irregular bleeding and menorrhagia
Prolapse of the uterus
Aetiology
Congenital in the
young and nulliparous
Normally the uterus
is held in by the pelvic floor muscles
Child birth - more
common in parous women especially multiple or difficult deliveries
Oestrogen deficiency
- postmenopausal atrophy - loss of muscle tone
Chronically raised
intra-abdominal pressure - obesity, chronic cough, straining at stool,
chronically stressed pelvic floor.
Pathophysiology
Prolapse means a
downward eversion of a hollow organ - may involve the rectum, uterus or urethra
May be first second
or third degree
Clinical
features
Feeling of `something
coming down`
Stress incontinence
Pain is variable
Sometimes backache
Complications involve
the urinary system
Management
Prevent with good care
of the pelvic floor muscles and perineum
Pelvic floor
exercises
Avoid raised
intra-abdominal pressure
Weight loss
Possible oestrogen
HRT
Ring pessary, changed
every 4 - 6 months
Oestrogen cream
Surgery
Cervical Cancer
Factors
Early age of first
sex Multiple
partners
A partner who has had
multiple partners Human
papilloma virus (HPV)
Herpes type 2
infection Smoking
Screening should
start when sex does Oral
contraception (100% increase after 10 years)
Features
Early disease is asymptomatic Post
coital bleeding
Discharge Irregular
bleeding
Pain with local
invasion Involvement
of bladder or rectum
Management
Depends on stage Local
treatment
Cone resection and
biopsy Hysterectomy
Radiotherapy
Ovarian Cancer
4th most
common cause of cancer deaths in women
Aetiology
Unknown
May be related to
ovulation - less in women who have taken oral contraception
Features
Usually presents late
Abdominal pain
Abdominal distension
Abnormal uterine
haemorrhage
Pathology
Mostly epithelial
Management
Depends on stage
Abdominal
hysterectomy with bilateral salpingo-oophorectomy
Cytotoxics
5-year survival is 25
- 30%
Benign ovarian neoplasia
May be solid, cystic
or mixed
Commonly present as asymptomatic
abdominal masses but may present
with pain or
functional effects
Ovarian Cancer
A
malignant neoplasm (abnormal growth) located on the ovaries.
Causes,
incidence, and risk factors
The
exact cause of ovarian cancer is unknown. Oddly enough, ovarian cancer is
fairly uncommon, yet it is the 5th leading cause of cancer death in women. It
is also the leading cause of death from gynecologic malignancies. This is a
result of a number of factors. Malignant tumors of the ovaries develop quickly,
often times involving both ovaries, and they shed malignant cells relatively
early in the disease. These cells, which frequently land on the uterus,
bladder, and bowel, can begin forming new tumor growths before cancer is ever
even suspected. In addition to the rapid rate of development, there is not a
screening test for ovarian cancer and symptoms of early disease are minimal, if
even present. For these reasons, over 50 percent of women with ovarian cancer
are in the advanced stages of the disease at the time of diagnosis.
Ovarian
cancer is more common in industrialized nations, with the exception of
Risk
factors include poor reproductive history (infertility, repeated spontaneous
abortions, delayed childbearing beyond age 30); past medical history of breast
cancer (twice the risk of other women); family history of breast cancer or
ovarian cancer in mother or sister; family history of Lynch syndrome II (the
familial pedigree includes cancers of the colon, lung, prostate, and uterus),
exposure to asbestos or high levels of radiation; high dietary fat; the use of
talcum powder in the genital area; and the use of estrogen (other than that in
oral contraceptives, which has actually been shown to have a protective
effect).
Prevention
Having
regular pelvic examinations and avoiding risk factors listed above may decrease
the overall risk; however, no complete prevention is known.
Studies
have shown that there may be a lower risk of ovarian cancer in patients who
have used the oral contraceptive pill. After five or more years of use, there
is a 60 percent reduction in the risk of ovarian cancer.
Symptoms
•sense
of pelvic heaviness•vague lower abdominal discomfort•vaginal
bleeding•weight gain or loss•abnormal menstrual
cycles•increased abdominal girth•non specific gastrointestinal
symptoms: increased gas, •indigestion, lack of appetite, nausea and
vomiting, inability to ingest usual volumes of food, bloating
Additional
symptoms that may be associated with this disease: - •urinary
frequency/urgency, increased•hair, excessive on females. Note: There may
be no symptoms until late in the disease.
Signs and
Tests
Physical
examination may reveal increased abdominal girth and /or ascites (fluid within
the abdominal cavity). Pelvic examination may reveal an ovarian or abdominal
mass.
Tests
include:
•a
CBC•blood chemistry•an HCG (quantitative)•a serum HCG (blood
pregnancy test)•alpha fetoprotein•a urinalysis•a GI
series•serum progesterone•pregnanediol•estriol -
urine•estriol - serum•estradiol -
test•17-ketosteroids•laparotomy exploratory•transvaginal
ultrasound•an abdominal CT scan or MRI of abdomen (quite limited
diagnostic capabilities in this illness)
Treatment
Surgery
is the preferred treatment and is frequently necessary for diagnosis.
Chemotherapy is most frequently used as adjunctive therapy. Radiation therapy
may be considered but is used less often than chemotherapy after surgery.
The
stress of illness can often times be helped by joining a support group where
members share common experiences and problems. See cancer - support group.
Prognosis
Ovarian
cancer is rarely diagnosed in its early stages; it is usually quite advanced by
the time diagnosis is made. The outcome is often poor: the 5-year survival rate
for all stages is only 35 to 38%. If, however, diagnosis is made early in the
disease, 5-year survival rates can reach 85%.
Complications
•spread
of the cancer to other organs•progressive function loss of various organs
Cervical cancer
Cancer
of the uterine cervix.
Causes,
incidence, and risk factors
Cervical
cancer is the third most common type of cancer in women. Approximately 2-3% of
all women over age 40 years will develop some form of cervical cancer. The
average age at diagnosis is 45 years, but it has been noted in women 20-30
years old. The cause of cervical cancer is unknown; however, a number of
predisposing factors (risk factors) have been identified. These include:
multiple sexual partners, early onset of sexual activity (less than 18 years),
or early childbearing (less than 16 years). Sexually transmitted diseases,
specifically HPV (Human papilloma virus - genital warts), HIV infection, and
genital herpes also appear to increase the risk of cervical cancer.
It
is now known that women who were exposed to the drug DES (Diethylstilbestrol)
in utero are at risk for developing certain rare vaginal and cervical cancers
along with many other abnormalities of the uterine, cervical and vaginal
tissues. DES is a drug that was once thought to prevent miscarriages.
Unfortunately, the risks of taking DES were not known and between 1940 and the
early 1970's many pregnant women received the drug in hopes of preventing any
suspected miscarriages. Clinical studies have shown the risk of cancer among
the daughters born to women who were taking the drug to be around 4 in 1,000.
The
development of cervical cancer is gradual and may take many years. Initially,
subtle changes occur in the superficial cells of the cervix. As these changes
become even more abnormal they cause dysplasia, which is a premalignant
condition of the cervix. The dysplasia can then progress to preinvasive cancer
which invades only the outer layer of the cervix. Eventually the cancer spreads
to the deeper layers, and ultimately, if untreated, to the other pelvic organs.
Routine
Pap smears are very effective at detecting abnormal cells, but it is very easy
to put off going to the doctor, especially when you aren't ill. There are no
symptoms in the early stages of cervical cancer and frequently symptoms don't
appear until after the invasive cancer begins to erode tiny blood vessels within
the cervix. The absence of symptoms allows the unsuspecting person to postpone
a much needed visit to the doctor. Proper treatment of cervical cancer that has
progressed to this early stage (see stages listed in the signs and tests
section) can save 80% of women. If, however, the cancer spreads to other organs
before treatment is initiated, the survival rate drops significantly.
Prevention
Deferring
sexual activity until older than 18 years of age, practicing monogamy, and
safer sex behaviors all reduce the potential for cervical cancer.
A
routine pelvic examination, including a Pap smear should be performed yearly
beginning at the onset of sexual activity, or by the age of 20 in non-sexually
active women. Pap smears detect abnormalities in the cells of the cervix, thus
alerting the physician that further tests may need to be done. Early detection
allows treatment to begin before cancer has actually developed.
Symptoms
•abnormal
vaginal bleeding
•between
menstrual periods•after intercourse•after douching•after
menopause
•persistent
vaginal discharge - pale, watery, pink, brown or blood streaked, may be dark
and foul-smelling
Advanced
disease symptoms include:
•anorexia
(loss of appetite)•weight loss•fatigue•back pain or leg
pain•involuntary loss of urine or rectal contents from the vagina through
an abnormal tube-like passage (fistula) that connects the vagina with the
bladder or rectum
Signs and
Tests
A
physical exam may show the cervix to be irregular, enlarged, firm, or friable
(bleeds easily) in the later stages of cervical cancer. However, the cervix
almost always looks normal in the early stages of the disease.
•Pap
smear shows abnormal cells, dysplasia, or cervical cancer.•Colposcopy
suggests cervical cancer and pinpoints areas of concern.•Cervical biopsy
(colposcopy-directed biopsy or cone biopsy) confirms cervical cancer.
STAGES OF
CERVICAL CANCER DETERMINED BY BIOPSY
•0.
carcinoma in situ: the tumor is non-invasive, involving only the superficial
surface of the cervix•1a. tumor penetrates no more than 3 mm below the
cervical lining boundary•1b. tumor involves the cervix and uterus
only•2. tumor extends to the upper vagina and/or supporting structures
alongside the uterus•3. tumor extends to the pelvic wall•4. tumor
extends to the bladder, rectum and/or distant sites (metastases)
Treatment
Options
for treatment depend on the extent of disease, the type of cancer, the age and
general health of the woman, and the desire for future childbearing. Surgery
may range from very localized for surface cancer (carcinoma in situ) up to a
radical hysterectomy (removal of the uterus and surrounding pelvic lymph nodes)
for invasive cancer that extends beyond the cervix. A cone biopsy, which is the
removal of a wedge of the cervix for biopsy, is sometimes enough to remove all
of the malignant cells of a surface cancer. Cryosurgery (destruction of tissue
by freezing it) is also used frequently to treat preinvasive cancer. A
hysterectomy is still the choice of many, but for those women with the desire
to have children in the future, these alternate methods frequently allow them
to do so.
Since
invasive cervical cancer frequently spreads to the adjacent pelvic lymph nodes,
more intense treatment is recommended. Radiation therapy, which is commonly
done either before or after surgery, chemotherapy, radical hysterectomy or a
combination of the three have all been used for successful treatment.
Prognosis
Many
factors influence the outcome of cervical cancer:
•age
of the woman•general physical condition and health•specific
features of the type of cancer•stage of the disease•skill of the
provider
The
5 year survival rates (number of people who live for at least 5 years) for
women with cervical cancer with appropriate treatment are approximately:
•80
to 85% for stage 1•50 to 65% for stage 2•30 to 40% for stage
3•up to 12% for stage 4
In
women with untreated or unresponsive cervical cancer, death occurs 95% of the
time within 2 years of the onset of symptoms.
Complications
•Some
types of cervical cancer are less responsive to treatment.•There may be a
recurrence of cancer.•Women who are treated with either a cone biopsy or
cryosurgery are at a high risk of possible recurrence.
Call
for an appointment with your health care provider if you are a woman who is
sexually active or you are at least 20 years old and have never had a pelvic
examination and Pap smear.
•every
year initially.•for women up to age 35 or 40: every 2 to 3 years after
having 3 negative, consecutive annual Pap smear tests and a single sexual
partner or no sexual partner.•every year for women over 35 or
40.•every year for women who have had multiple sexual
partners.•every year for women who are taking oral contraceptives (birth
control pills).•every 6 months for women who have a history of HPV
(genital warts).•every 6 months for women who were prenatally exposed to
DES.•the frequency recommended after an abnormal Pap smear.
Fibroids
Benign
tumors of muscle and connective tissue that develop within or are attached to
the uterine wall.
Causes,
incidence, and risk factors
The
cause of fibroid tumors of the uterus is unknown. However, it is suggested that
fibroids may enlarge with estrogen therapy (such as oral contraceptives) or
with pregnancy. Their growth seems to depend on regular estrogen stimulation,
showing up only rarely before the age of 20 and shrinking after menopause. As
long as a woman with fibroids is menstruating, the fibroids will probably
continue to grow, although growth is usually quite slow. Fibroids can be
microscopic, but they can also grow to fill the uterine cavity, weighing
several pounds. Uterine fibroids are the most common pelvic tumor and they may
be present in 15 to 20% of reproductive-age women, and 30 to 40% of women over
30. Fibroids occur 3 to 9 times more frequently in African-American women than
in Caucasian women.
It
is possible for a single fibroid to develop although normally there are a
number of them, which begin as small seedlings spread throughout the muscular
walls of the uterus. They slowly enlarge and become more nodular, frequently
intruding into the cavity of the uterus or growing out beyond the normal
boundary of the uterus. Rarely, a fibroid will hang from a long stalk attached
to the outside of the uterus. This is called a pedunculate fibroid.
Prevention
Prevention
is unknown.
Symptoms
•sensation
of fullness or pressure in lower abdomen•abdominal fullness,
gaseous•increase in urinary frequency•presently in a menstruating
age and having heavy menstrual bleeding (menorrhagia), sometimes with the
passage of blood clots•sudden, severe pain (a pedunculate fibroid twists
causing the blood vessels feeding the tumor to kink) Note: Hospitalization and
surgery may be needed in this instance,
Note:
There may be no symptoms.
Signs and
Tests
A
pelvic examination reveals an irregularly shaped, lumpy, or enlarged uterus.
Frequently, this diagnosis is reliable, however, on occasion, diagnosis is
difficult, especially in obese women. Fibroid tumors have been mistaken for ovarian
tumors, inflammatory processes of the tubes, and pregnancy.
A
transvaginal ultrasound or pelvic ultrasound is usually performed to confirm
the findings.
A
D&C procedure or a pelvic laparoscopy may be necessary to rule out other,
potentially malignant, conditions.
Treatment
Methods
of treatment depend on the severity of symptoms, age, pregnancy status, desire
for future pregnancies, general health, and characteristics of the fibroid(s).
Treatment may consist of simply monitoring the fibroids, specifically their
rate of growth, with periodic pelvic exams or ultrasound. This method is
usually sufficient in pre menopausal women.
Hormonal
treatment, involving drugs such as Nafarelin and Leuporlide, causes fibroids to
shrink. This method is sometimes used in pre-menopausal women who desire to
bear children, but have problems conceiving because of the tumors. If fibroids
become large enough, they may block the fallopian tubes or fill the uterine
cavity. The hormones produce an environment in the body that is very similar to
that of menopause, thus, pseudo-menopause. The treatment spans over several
months and during this time the reduction in estrogen concentration allows the
fibroids to shrink. Since fibroids will begin to enlarge as soon as treatment stops,
the woman is encouraged to begin attempting to conceive almost immediately.
For
women who do not want to conceive, but also don't want to undergo surgery,
hormone treatment is frequently an option. The side effects of this type of
treatment usually include menopausal symptoms, which for some women may be
rather annoying. If treatment is discontinued, fibroids will regrow and another
method of treatment will need to be used.
A
myomectomy, which is a surgical procedure to remove just the fibroids, is frequently
the chosen treatment, especially for pre-menopausal women who want to bear more
children. Another advantage of a myomectomy is that it controls pain or
excessive bleeding that some women with uterine fibroids experience.
A
total hysterectomy, which involves removal of the uterus, is another option.
Prognosis
Prior
to menopause, fibroids are likely to grow slowly. Women with known fibroids who
choose to have children, may be counseled to become pregnant earlier in adulthood.
As a general rule, fibroids don't interfere with fertility, however, on
occasion a tumor will block the fallopian tubes and prevent sperm from reaching
and fertilizing the egg. In some cases, fibroids may prevent the fertilized egg
from implanting in the uterine lining. However, proper treatment may restore
fertility.
After
a pregnancy is established, existing fibroids will grow due to the increased
blood flow and estrogen levels. These usually return to their original size
after the baby has been delivered. Many women are able to carry their babies to
term, but some of them end up delivering prematurely because there is not
enough room in the uterine cavity to sustain full term. Cesarean section is
often needed for delivery since fibroid tumors may block the birth canal or
cause the baby to be positioned abnormally. After menopause, new fibroids
rarely develop and those already present usually shrink.
Complications
Fibroids
may cause infertility because they interfere with conception or implantation.
They may cause premature delivery because of decreased area within the uterine
cavity. Severe pain or excessively heavy bleeding with fibroids may necessitate
emergency surgery. Rarely, malignant changes may occur, however, these usually
take place in postmenopausal women. The most common warning sign is rapid
enlargement of a fibroid and definitive diagnosis is usually not made until the
time of surgery.
Calling your
health care provider
Call
for an appointment with your health care provider if gradual changes in your
menstrual pattern occur (heavier flow, increased cramping, bleeding between
periods); or if fullness or heaviness develops in your lower abdomen.
Frequently there is associated pressure or discomfort and interference with
normal urination frequency.