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This is most common tumour in gynaecology. Fibroids arise from the uterine muscle, that’s why called myoma. Although rarely become cancerous, fibroids can cause various problems for the patients. These include heavy period, lower abdominal pain, urinary problems, painful menstruation etc. But many fibroids are asymptomatic and may not need treatment.
There are basically three types of fibroids- subserous fibroid, intramural fibroid, submucous fibroid. Fibroids are named according to their position within the uterus; submucosal, intramural, and subserosal. A submucosal fibroid lies just under the inner lining of the uterus, which is called the endometrium. Some of these fibroids grow on a stalk. These are referred to as "pedunculated" or fibroid polyp. An intramural fibroid that lies completely within the muscular wall of the uterus ("intra" means within and "mural" means wall). A serosal or subserosal fibroid lies on the outer part of the uterus, just under the covering of the outside of the uterus, which is called the serosa. Subserosal fibroids may also grow on a stalk and be called pedunculated. Most of the sub serous fibroid are asymptomatic and do not need treatment. Submucous fibroids are most troublesome but can be treated by hysteroscopic surgery (No Hole No Cut Surgery). Intramural fibroids, if symptomatic, may be treated by either myomectomy (removal of fibroid only) or hysterectomy. Myomectomy can be done by abdominal & laparoscopic route. Hysterectomy can be done by abdominal, laparoscopic or vaginal route (No Hole No Cut Surgery) depending on expertise of the surgeon and clinical situation.
Fibroids and Fertility
It has often been suggested that infertility and/or repeated miscarriage can be caused by fibroids. However, the statistical evidence for this is lacking and other factors are more likely to cause infertility in fibroid patients. Some researchers have suggested that the presence of fibroids may predispose a patient to miscarriage, but again firm statistical evidence to support this possibility is not yet available except fibroid polyp. There have been studies in infertile women in whom the only identifiable cause is the presence of fibroids. However, because large studies have not been completed and infertility may have many causes, it is imprudent to assume that fibroids are the cause without a careful evaluation for other problems.
Any fluid filled structure is called cyst in medical language. Ovarian cyst is very common gynecological condition because numerous tiny fluid filled structures named follicles already exist within ovary in which the egg matures. So, most of the ovarian cyst is not sinister and actually resolves automatically or with simple medications combined contraceptive pills. The problem is, disease like endometriosis, abcess, hydrosalpinx (water accumulation in tubes) or even different types of ovarian cancer may appear as a “cyst” with ultrasonography. An expert radiologist and consultation with experienced gynecologist should be the all which is needed. In many occasions, patients with PCOS suffer from anxiety of ‘cyst’ as the word “cyst” is mentioned in ultrasonography reports. This should be clearly explained that “cyst” is not the problem of PCOS patients and surgical intervention is only needed rarely. Chocolate cysts are actually not ovarian cyst in true sense but a pseudocyst. Actually it is a collection of endometriotic tissue on ovary. That should be treated as the principal of treatment of endometriosis. Operative intervention in reproductive age group women is only needed when a ovarian simple cyst enlarge upto 4-5 cm to threaten ovarian tortion or cyst rupture. Laparoscopic cystectomy is ideal. Childhood ovarian cysts should be investigated thoroughly and laparoscopic surgery is usually preferred. A complex cyst ( ovarian cyst with solid component) at the perimenopausal /menopausal age should always be seen with suspicion and investigated. Threshold of surgery is lower in this age group. Serum CA125 is commonly done in case of ovarian cyst but false positive & false negative results are also very common and cause anxiety. But you should know that CA125 can be increased with menstruation, endometriosis, or any other cause of peritoneal irritation.On the other hand, it may not rise in early ovarian cancer. To overcome this problem RMI to be calculated before ovarian cyst surgery.
Endometriosis is one of the very bad chronic gynecological diseases. It can be very painful, can make women infertile, and throw them into a long term sufferings. However, in first stages it may be almost asymptomatic as well or patient can have pain only during menstruation which is generally thought to be normal by many. When endometrium ( the inner linning tissue of endometriosis) like tissue grows outside the uterus, it is called endometriosis. The cause of endometriosis is not fully known.
It is a gynecological disease of reproductive period and resolves after menopause. At first, patient present with vague gynecological symptoms like pain during menstruation, lower abdominal pain or heavy menstruation. But patient may remain relatively symptom free and present with infertility.
Treatment must be done by properly trained gynecologist as there is no standard treatment for all. Treatment should be individualized by the patient’s gynecological expectations (family size, sexual activity etc.), and also according to complexity of disease at presentation to gynecologist. (amount of adhesion, size of endometrioma etc). Oral hormonal pills, large doses of injectable hormone (progesterone), GnRh analogue injections, and different gynecological surgeries are available to fight with different presentations & pathologies created by endometriosis. The surgeries include laparoscopic excision of endometrioma, adhesiolysis, burning of endometriotic spot on the pelvic wall etc. But all the patient should be explained that this chronic gynecological condition can recur unless total hysterectomy with bilateral oophorectomy is done. Any gynecological surgery in endometriosis patient should be done by a skilled and experienced gynecological surgeon because normal anatomy is often distorted due to adhesions in pelvis.
When female genital organs come down from their normal position, it is said to to be prolapsed. A sense of bulging or protrusion in the vagina (“something coming out”) is the most common symptom. If neglected, it progress to cause several problems including retention of urine, hydronephrosis of kidney, difficulty in passing stool, decubitus ulcer, and walking difficulty etc. Evaluation need a proper pelvic examination by an expert gynecologist or urogynecologist.
Gynecologists divide genital prolapse into different types but they often co-exist. When the urinary bladder comes down it is called cystocele. When the rectum comes down through vagina it is called rectocele. When rectum comes down through anal orifice it is called prolapsed rectum. When uterus comes down it is uterine prolapse. When peritoneal pocket comes down through vagina it is called enterocele. When the vaginal stump (after hysterectomy) comes down it is called vault prolapse. This gynecological condition commonly seen in menopausal & aged women but even young patients can have genital prolapse.
Management options for women with symptomatic prolapse include observation, pelvic floor muscle exercise, mechanical support (pesaries), and surgery. Pelvic floor exercise can slow down the progress of this gynecological condition and should always be advised. Pessaries and observation may be useful in patients with many co-morbid conditions where surgery have a high risk. Active treatment is mostly surgical except minor degree of prolapse. In aged patients ( with many co-morbidities like hypertension, diabetis, sleep apnea etc) medical fitness need to be checked before undertaking surgery. Various types of surgeries are available and only an experienced gynecologist should decide on surgery as the surgical procedure should be individualized depending on various factors like type of prolapse, patient’s expectation, age and other medical illness. (e.g.chronic cough)
A young patient with expectation of another pregnancy with more than 1st degree prolapse should be having sacro-cervicopexy whereas a post menopausal lady may be better with vaginal hysterectomy with anterior & posterior colpopexy. A vault prolpase patient should not be having only anterior & posterior colpopexy but need sacrospinous fixation or sacrocolpopexy. So, surgical procedure need to be individualized and only decided by a experienced gynaecologist with special interest to pelvic floor. This is why recurrence of prolapse is not uncommon. In recent time, different types of mesh are coomercially available to reduce the recurrence rate. However extreme caution is needed before decision of mesh repair is taken and decision need to be taken by an expert gynecologist in consultation with patient & family.
PCOS is a common gynecological condition of young urban adolescent girls. PCOS ( poly cystic ovarian syndrome) is a misnomer as this is not characterized by ovarian cyst. The name is given by USG appearance of multiple crowded follicle at the cortex zone of ovary. This is actually a metabolic syndrome and characterized by anovulation, androgen excess, together with typical USG finding.
Two of the three following criteria are diagnostic of the condition (Rotterdam criteria): •Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3)
•Oligo-ovulation or anovulation
•Clinical and/or biochemical signs of hyperandrogenism
Generally PCOS patients present to gynecologists with Very little /no menstruation. Infertility can also be the presenting problem. Other symptoms can be skin and cosmetic problems like acne , excessive body hair growth, excessive scalp hair fall etc. and some patient may present to the dermatologist or cosmetic experts.
Life style modification is the most important tool to fight this gynecological condition. Sometimes simple oral pill together with life style modification may be all what is needed. Medications to treat the root cause of this gyne- metabolic condition are available and most of the patients get cured. In very few patients with infertility problem (not responding properly to ovulation induction regime) may be suitable for surgical treatment (laparoscopic ovarian drilling)
Early consultation with an expert gynecologist should decrease the need of surgical intervention.
Sexual problem can happen to any male or female. Here we mainly discuss about the sexual problems of a female which commonly present to gynecologists. A sexual problem, or sexual dysfunction, refers to a problem during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity. The sexual response cycle has four phases: excitement, plateau, orgasm, and resolution. While research suggests that sexual dysfunction is common (43% of women and 31% of men report some degree of difficulty), it is a topic that many people are hesitant to discuss with a qualified medical practitioner. Fortunately, most cases of sexual dysfunction are treatable, so it is important to share your concerns with your partner and gynecologist. The researchers developed the Female Sexual Function Index (FSFI) for assessment and treatment of women who suffer from sexual problems.
There are some sexual problems like inhibited sexual drive or inability to be aroused are better treated by psychologist than a gynecologist. But some problems like vaginismus, painful sexual intercourse and looseness of vagina & perineum should be treated by a good gynecologist.