Gynaecology

In brief

For many women, gynecologists often serve as both specialist and primary care provider, and as such, are given an opportunity to prevent and treat a wide variety of diseases. The incidence of these may vary greatly depending on the age group treated. Thus, the focus of medical questioning should reflect these changing risks.

 

Fertility

A lack of fertility or concerns about a lack of fertility is something that worries a larger number of couples.

It has been shown that if a couple are having regular unprotected sexual intercourse, then there is an 80% chance of conception after 12 months and a 90% chance of conception after 18 months. It is therefore very common to wait for a year or more before investigating the couple who are trying to conceive.

There are three main causes of infertility. A woman needs to produce eggs regularly and at the right time of her menstrual cycle, the man needs to produce sperm of the right quality and quantity, and the two need to be able to meet and therefore the women's fallopian tubes need to be open and undamaged.

About 25% of infertility is due to a lack of eggs, about 25% is due to a problem with the sperm, about 25% is due to tubal problems and in the final 25% the reason for infertility is never discovered (so called unexplained infertility).

Ovulation

The vast majority of healthy women between the ages of 15 and 40 will ovulate regularly. A regular menstrual cycle, especially if it is approximately 28 days, gives a strong indication that the women is ovulating. In addition, the mucus produced by the cervix is often very thin and runny at the time of ovulation and some women can detect this. Some women experience short but sharp pains in the pelvis at the time of ovulation, which is normal. Ovulation usually occurs 14 days before the first day of a period (therefore in a 28 day cycle it occurs 14 days after the first day of the period as well). A simple blood test measuring the progesterone level one week before a period is due is usually sufficient to confirm ovulation. Alternatively, a series of ultrasound scans starting at the beginning of the cycle can show the progress of an egg being produced.

Male Factor

A man is expected to produce at least 20 million sperm per millilitre of semen. Those sperm need to be of good quality. A past history of surgery on the testes or certain infections such as mumps or orchiditis can cause a decrease in sperm production. A semen analysis involves collecting a sample of the ejaculate and analysing it under the microscope.

Tubal Factors

A patient who has had previous surgery in the pelvis or previous infection in the pelvis, may be at risk of having damage to the fallopian tubes. Damage to the fallopian tubes can also be caused by endometriosis. There are two commonly used tests to investigate the patency of the fallopian tubes. A hysterosalpingogram is an investigation done in the X-Ray department where a dye is inserted through the cervix and X-Rays are taken showing the progress of the dye up through the uterus and out through the fallopian tubes. An alternative investigation is to perform a laparoscopy, which is a minor operation done under general anaesthetic (see laparoscopy). Dye can be inserted through the cervix and into the uterus and tubes and can been seen spilling out of the ends of the tubes under direct vision through the laparoscope.

Miscarriage

A miscarriage is a very common event. Approximately 10 to 15% of pregnancies result in a miscarriage. The majority of patients develop bleeding and sometimes pain in the early stages of pregnancy. The commonest time of miscarriage is between 7 and 12 weeks from the last period. Approximately 50% of miscarriages are caused by chromosomal abnormalities. This means that the pregnancy was developing abnormally and was never going to develop into a full grown baby. Most chromosomal abnormalities are spontaneous or sporadic. They are not usually caused by something inherited. Either the growth of cells in the early stage of pregnancy has not occurred perfectly or an egg which did not consist of a perfect compliment of chromosomes is fertilised. Many people describe the consequence of miscarriage as being nature's way of dealing with an abnormally growing pregnancy.

There are many other less common causes of miscarriage. Smoking or use of cocaine and other recreational drugs as well as certain chemical agents, such as lead, solvents and pesticides, have been implicated in miscarriages. Certain infections such as listeria or malaria are also causes of miscarriage. In recent years we have discovered that certain blood clotting problems can also be the cause of miscarriage.

The majority of miscarriages can be diagnosed with a single ultrasound scan. Some miscarriages are best treated with surgical evacuation of the tissue left inside the uterus, whilst other miscarriages are best treated conservatively, allowing the products of conception to pass spontaneously.

Ectopic Pregnancy

Ectopic pregnancies occur in approximately 1 in 100 pregnancies. The problem is that a pregnancy has implanted and started to grow in the wrong place.

A pregnancy is supposed to implant and grow inside the uterus, but it can implant and grow in the fallopian tube, which is the commonest site for an ectopic pregnancy. The danger of ectopic pregnancies is when the growth of the pregnancy tissue causes an expansion and rupture of the fallopian tube. This can cause very sudden and severe bleeding. Most women with an ectopic pregnancy complain of pain and bleeding in the early stages of pregnancy and the commonest time for presentation is 6 to 8 weeks after the last period. The majority of women with ectopic pregnancies have no previous risk factors. However, a previous ectopic pregnancy or a history of pelvic operations or pelvic infection can significantly increase the chances of an ectopic pregnancy.

Most women presenting with an ectopic pregnancy will have tenderness on one side of the pelvis on examination. Sometimes the diagnosis is obvious, but most of the time further investigations will be required in order to make the diagnosis. An ultrasound scan is performed to exclude an intrauterine pregnancy. If on ultrasound a pregnancy is seen inside the uterus then the chances of an ectopic pregnancy are very small. Sometimes an ultrasound scan can actually see an ectopic pregnancy. Sometimes the ultrasound scan gives clues, such as having fluid in the pouch of Douglas. There are occasions where a blood test such as a B-LCG level or a progesterone level can be performed and this gives extra information about the likelihood of an ectopic pregnancy.

In various circumstances an ectopic pregnancy may be treated by surgery or by medical treatment. If there is any suspicion of rupture of the ectopic pregnancy then surgery is appropriate. The diagnosis and treatment is usually possible by performing a laparoscopy. Medical treatment is sometimes appropriate and usually the drug methotrexate is used. Following this type of treatment, monitoring of blood levels of B-LCG may be necessary to ensure the treatment’s success.

Menopause

The menopause is the time in life when a women stops having periods. The periods stop because the ovaries stop producing the normal amounts of oestrogen and progesterone hormones. For many people the menopause is uneventful and without adverse symptoms. On average in the Western world, the menopause occurs at the age of 51. Some women have a series of different symptoms at the time of the menopause that leads them to seek help and treatment.

Short term symptoms

Hot flushes and night sweats are very common at the time of the menopause. These can occur at any time and be debilitating. Mood swings, irritability and loss of concentration are also recognised symptoms of the menopause. In addition, the skin of the vagina and the supporting tissues of the pelvis become thinner and weaker at the time of the menopause and very often cause some discomfort and minor infections. Women often describe a decrease in libido (sex drive) as well.

Long term complications

Osteoporosis is the commonest long term complication of the menopause. A lack of estrogen causes the bones to thin slowly. This process is called Osteoporosis and over many years increases the chances of a bone fracture. Severe cases of Osteoporosis can result in spinal problems and a decrease in height or in hip fractures with minimal trauma. The instance of coronary heart disease and strokes is much lower in women before the age of the menopause. However, after the menopause the incidents of coronary heart disease increases significantly.

A simple blood test can be performed to determine whether a women’s ovaries have stopped working. Hormone Replacement Therapy comes in many different forms and can be taken by tablet or stuck on the skin in the form of a patch or absorbed by rubbing in a gel or by sniffing a nasal spray or sometimes by inserting a small implant. Over recent years the arguments for and against HRT have become very complex.

Fibroids

Uterine fibroids are the most common benign pelvic tumor in women. They are also called leiomyomas or myomas. Fibroids are caused by an over growth of the muscle of the uterus. They are often round or oval in shape and firm in consistency. They may be single or multiple and can arise in different layers of the uterus. Fibroids arising next to the uterine cavity (endometrium) lining are called submucosal. Fibroids arising in the muscular layer of the uterus are called intramural. Those arising under the surface of the uterus are called subserosal. The location of the fibroid may dictate the type of symptoms the woman has.

Fibroids grow in the presence of the hormone oestrogen, but following the menopause the majority of fibroids shrink. Fibroids only need to be treated if they are causing problems. They may cause a problem because of their size which may vary from microscopic to the size of a football. They can cause pressure on the bladder or on the bowel or cause a swelling in the lower abdomen which is noticeable. Alternatively, fibroids can have an effect on women's periods. They often cause very heavy periods, especially if the Fibroid affects the lining of the uterus. Fibroids may also cause infertility or miscarriages. Occasionally they cause pain and this is most common in pregnancy.

African and afro-caribbean women have more than three times incidence of symptomatic fibroids when compared with Caucasians.

Endometriosis

Endometriosis is an extremely common condition which can affect women in a variety of ways. It occurs when the cells which normally line the uterus (endometrium) are found in other parts of the pelvis. The cells behave exactly the same as they do when they line the uterus and therefore each month they grow and at the time of a period then they bleed. Bleeding inside the pelvis can often cause pain. Therefore, most patients with Endometriosis initially have problems with pain at the time of their periods. After many months and years of this internal bleeding, then scar tissue may form, together with cysts on the ovaries. Women with severe Endometriosis may have pain at any time of their menstral cycle and may have adhesions in the pelvis which cause problems. In addition to the pain which is caused by Endometriosis, this condition can also cause problems with fertility.

Most patients have the diagnosis of Endometriosis confirmed by a laparoscopy operation. At this laparoscopy then mild to moderate Endometriosis can be treated with the laser or another similar ablation method. This is a very effective way of treating early Endometriosis. A variety of hormonal treatments may be useful in controlling the symptoms of Endometriosis. Common hormonal treatments include the oral contraceptive pill, the mirena IUS, progesterone treatments, danasol and GnRH hormone injections.

Incontinence

There are two common types of incontinence, both of which occur more commonly in older women. Stress incontinence is the term used to describe the leakage of urine with various types of physical exercise, such as coughing, sneezing and straining. Urge incontinence occurs when the bladder automatically empties each time it is full. When a women has the urge to pass urine she has to quickly get to the nearest toilet or she will be incontinent.

The treatment of stress incontinence often involves the strengthening of the ligaments in the pelvis and the supports of the bladder. This usually requires surgery. Urge incontinence is not helped by surgery. Various treatments including bladder retraining techniques and drugs to inhibit the contraction of the bladder can be very successful.

It is important that any patient complaining of incontinence problems undergoes urodynamics investigations before the appropriate treatment is determined.

Infections

Urinary Tract Infections

Urinary Tract Infections (UTIs) are very common infections in the female population. The commonest time to experience a urinary infection is in pregnancy or in the older age group but they can occur at any time. The main symptom is pain on passing urine and sometimes blood is seen in the urine. A urine sample can be sent to the laboratory to check for infection and a reliable result can be obtained. This urine sample can determine which particular antibiotics are best used to treat this urine infection. If a urine infection is left untreated then it can spread up the urinary tract and affect the kidneys. It is therefore important to treat a urinary tract infection early.

Pelvic Inflammatory Disease

Pelvic Inflammatory Disease is increasing, especially in the younger age group. Sexually transmitted organisms such as Chlamydia and Gonococcus are increasing in prevalence. Pelvic Inflammatory Disease is usually an infection of the fallopian tubes but it can also involve the uterus and the ovaries if it becomes severe. It usually affects both sides. Most patients present with a vaginal discharge which is smelly and pain in the pelvis. On examination they are tender in the pelvis. A swab can be taken to check for different organisms and appropriate antibiotics given.

Pelvic Inflammatory Disease can cause damage to the fallopian tubes which result in infertility later in life. Most pelvic infections are readily detected because the patient presents with symptoms. However, it is possible to have a Chlamydial infection without realising. Fortunately, Chlamydia is always sensitive to doxycyline antibiotic but it can cause some damage to the fallopian tubes it is present for some time without the patient realising.