Case Adnexa Endometriosis

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6/25/2014 Gynaecology, Endometriosis, Fibroids, Menstrual Bleeding | Sydney Gynaecology & Endometriosis Centre, Sydney

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Endometriosis

Uterine fibroids

Heavy menstrual bleeding

Abnormal Pap smears

This information package is designed for general information and is not a substitute for a medicalopinion. It will

you to make an informed de cision after you have discussed your options with your doctor and a tailor-made care

has been formulated.

ENDOMETRIOSIS

What is endometriosis?

The uterus (womb) has a cavity in which a baby grows. Part of this lining (called endometrium) is shed every m

and results in menstruation (a period). When this lining grows outside the ute rus, we call it endometriosis. One in

women (10%) of menstruating age have endometriosis, so it is considered common. It can occur from the ag

puberty to beyond the menopause as well.

Endometriosis causes scar tissue and can result in the uterus, ovaries, fallopian tubes and bowel becoming stuc

each other and to the lining of the tummy. Here are some photos of what endometriosis looks like and photoendometriosis that has been excised (cut out) for treatment.

Click to view Image

Normal pelvis with normal

uterus, ovaries, fallopian

tubes and pouch of Douglas

Click to view Image

Endometriosis o f lining of

right pelvic sidewall &

uterosacral ligament

Click to view Image

Endometriosis o f lining of

right pelvic side w all &

uterosacral ligament. Normal

right ovary.

Click to view Image

Endometriosis o f lining o f

left pelvic sidewall

Click to view Image

Endometriosis of both pe lvic

sidewalls, uterosacral

ligaments & pouch of

Click to view Image

Endometriosis of left pelvic

sidewall and pouch of

Douglas

Click to view Image

Endometriosis that is being

cut out from the pelvic

sidewall

Click to view Image

Endometriosis has been

excised from the right pe

sidewall and pouch of

Related Searches

Heavy Menstrual

Bleeding

Fibroid Growth

Symptoms Of

Endometriosis

Menstrual Period

Information On

Endometriosis

Diagnosis Of

Endometriosis

Treatment For

Fibroids

Menstrual Bleeding

Removal Of Fibroids

DiVapton
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Douglas Douglas

What causes endometriosis?

Although the exact cause of endometriosis is still unknown, there are a number of theories about how it develop

is believed that a number of causes exist together to cause this disease.

The most likely explanation is that cells lining the tummy change into the type of cell that line the uterus. S

endometriosis probably results from menstrual fluid flowing backwards through the fallopian tubes and deposits in

tummy. There is a genetic component to endometriosis and women who have a mother or sister with endometri

are more likely to have it as well. There is a change in the immune systemin women with endometriosis. Most wo

have a natural defense which gets rid of menstrual fluid in the tummy. Women with endometriosis have a redu

ability to clear it or to prevent its growth once it has settled on the lining of the tummy. The hormone oestro

produced by the ovaries is also required to grow endometriosis. That is why after the menopause when the ova

stop functioning and the oe strogen becomes very low, usually the pain w ith endometriosis settles down.

Factors reducing the risk of endometriosis

1. Aerobic exercise of five hours per week has been shown to reduce the risk of recurrence of endometriosis.

2. Having a child reduces the risk of recurrence by about 50%.

3. Similar to pregnancy, the oral contraceptive pillalso has a protective effect. It keeps the ovaries quiet and there

no ovulation (egg production and release ). The pill prevents the surge in oestrogen that normally occurs.

Back to Top

What problems does endometriosis cause?

Pain with periods

This is the most common pain with endometriosis. Period pain usually starts with the first time a woman has

periods. In many women period pain may start after many yearsof having fairly pain-free periods. These wo

particularly are likely to have endometriosis. However one needs to remember that about 70% of women in the w

have period pa in that is normal without any underlying reason except that they are having periods. A woman may

have any pain despite quite advanced endometriosis. She may see her doctor because she cannot get pregnant.

severity of endometriosis often does not correlate with the severity of pain. Women with little endometriosis may h

a lot of pain or they may have a great deal of endometriosis and not much pain at all.

Pain with sex

If there is endometriosis on the vagina and forms scar tissue, it can be painful during sex be cause the vagina ca

stretch. Pain may also occur due to nerves being involved in that area. Pain can particularly be painful when vag

intercourse occurs just prior to periods (or during periods if vaginal intercourse occurs during that time).

Click to view Image

Endometriosis on the backof the vagina

Pain when opening bowels

Pain that occurs when a woman opens her bowels is usually an indication of advanced endometriosis. Endometr

would involve the wall of the bowel or may just cover the space between the uterus, vagina and bowel. This are

called the pouch of Douglas and basically is the area a woman sits on, that is, the bottom of the tummy. Here

diagram and a photo of this area.

Click to view Image

Click to view Image
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Normal back wa ll of vagina, pouch of Douglas &

uterosacral ligaments

Severe endometriosis with d istortion of pelvic anatomy

Endometriosis on back of uterus & rectum (lower pa rt o

bowe l) is attached to vagina and uterus. Left ovary

attached to back of uterus.

Pain when ope ning bowels can sometimes be so severe that a woman is doubled over in pain on the bathroom flo

Examination

A gynaecological examination by your doctor is very important. Your GP or gynaecologist would have a feel of

tummy, and then examine the vagina with a speculum. This is the instrument used to take a Pap smear. A vag

examination is then performed w hich may reveal an area o f tenderness. The doctor may also feel some nodulari

the vagina which would indicate scar tissue behind the vagina or on the bow el.

Often the gynaecological examination is perfectly normal. This does not exclude endometriosis, as a w oman may st

have mild or moderate disease which has not caused significant scar tissue to be able to be felt on vaginal

examination.

Ultrasound

The only abnormality an ultrasound w ould pick up is a cyst of endometriosis in the ovaries. This is called a choco

cyst because it is filled with old blood that looks like melted chocolate. When we see chocolate cysts in the ovarie

usually means advanced endometriosis. In general these cysts develop once endometriosis has grown in a lo

areas of the tummy already.

Laparoscopy

Laparoscopy is the only way w e can make a definite diagnosis of endometriosis . This is also called keyhole surg

which is done under general anaesthetic in hospital. Very small cuts (half a centimeter) are made in the tummy an

laparoscope (this is like a telescope) is inserted through the belly button. The laparoscope is connected to a cam

and television, so the surgeon can visualize all the gynaecological organs.

Here are photos of what a normal pelvis and abdomen look like.

Click to view Image

Normal pelvis with normal

uterus, ovaries & fallopian

tubes

Click to view Image

Normal liver and diaphragm

|

Click to view Image

Normal appendix

Click to view Image

This is the area in front o

the uterus where the

bladder is. The lining

between the uterus &

bladder is normal in this

photo.

If endometriosis is present, the surgeon excises it (cuts it out). Laparoscopic excision of endometriosis requires a h

degree o f skill by the surgeon. Therefore the surgeon would have had special trainingin this type of operation.

Laparoscopy has many advantages over open surgery where a big cut is made in the tummy, like a caesarean sec

cut. Women experience much less pain, recover more quickly, there is minimal scarring and reduced risk of infection

Please have a look under the heading Laparoscopy

Peritoneum

The peritoneum is the lining of the pelvic organs. Endometriosis most commonly affects the peritoneum.

Click to view Image

Endometriosis of both

pelvic sidewalls,

uterosacral ligaments

Click to view Image

Superficial

endometriosis of right

pelvic sidewall

Click to view Image

Superficial

endometriosis of both

pelvic sidewall

Click to view Image

Superficial

endometriosis of left

pelvic sidewall

Click to view Image

Endometriosis of b

uterosacral ligamen
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& pouch of Douglas peritoneum peritoneum peritoneum

Click to view Image

Excised endometriosis

of left uterosacral

ligament

Click to view Image


of both pe lvic sidewall

peritoneum

Click to view Image

A blood vessel

underneath

endometriosis near an

ovary on the pe lvic

sidewall

Click to view Image


of left pelvic sidewall

peritoneum

Click to view Image

Excised endometrio

of right pelvic sidew

peritoneum,

uterosacral ligamen

pouch of

Douglas

Click to view Image


of left uterosacral

ligament, pelvic

sidewall peritoneum &

pouch of

Douglas

Click to view Image


of both uterosacral

ligaments, pelvic

sidewall peritoneum &

pouch

of Douglas

Click to view Image


of left uterosacral

ligament & pelvic

sidewall peritoneum

Click to view Image


of left uterosacral

ligament & both pelvic

sidewall peritoneum

Click to view Image

Excised endometrio

of left uterosacral

ligament & pelvic

sidewall peritoneum

Ovary

A cyst of endometriosis in the ovary is called a chocolate cyst because it is filled w ith old blood that looks like me

chocolate. The medical word for it is endometrioma. Here is an e xample o f an endometrioma.

Click to view Image

Endometriosis of right pelvic sidewa ll extending underneath ovary. Right ovary densely attached to sidew all.

Uterus

Endometriosis is often seen on the back of the uterus where it affects the outer layer. One can see reddish or clea

coloured areas o f endometriosis.

Here is an example of endometriosis affecting the uterus.

Click to view Image

Severe endometriosis

Complete obliteration of pouch of Douglas. The bowe l is densely adherent to uterus, so only top of uterus is visible

normal anatomy of pouch of Douglas is present.

Rectum and vagina

When endometriosis affects the vagina, women often feel pain during sex. This occurs because scar tissue prev

the vagina from stretching or because nerves are affected by endometriosis. The rectum is the lowest part of

bowel behind the anus. The anus is where one opens the bowels. When endometriosis affects the bowel, wo

have pain with sex and on opening bowels. Rarely bleeding from the anus may occur during periods. Here i

example of endometriosis a ffecting the rectum and vagina.

Click to view Image

Severe endometriosis of vagina and pouch of Douglas.

Both ovaries are adherent to pelvic side wa lls.

Click to view Image

Severe endometriosis. Complete obliteration of pouch o

Douglas. The bow el is densely adherent to ute rus, so t

normal space betwee n vagina & rectum (lower pa rt of

bowe l) is not present.

Bladder

Endometriosis often affects the lining over the bladder. Rarely it can go deeper into the muscle of the bladder

cause pain when a women passes urine or there may be blood in the urine. Here is an example of endometri

affecting the lining over the bladder.

Click to view Image

This is the area in front of

the uterus where the

bladder is. The

lining(peritoneum) between

the uterus & bladder is

normal in this

Click to view Image

Endometriosis near

peritoneum between uterus

& bladder

Click to view Image

Endometriosis of peritoneum

between uterus & bladder

Click to view Image

Excised endometriosis o f

peritoneum between ute

& bladder
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Below ribcage or diaphragm

Rarely a women may have endometriosis in the lining underneath the ribs higher up in thetummy. This can cause

in the upper tummy during periods. Here is an example ofendometriosis below the ribcage on the right.

Click to view Image

Normal liver & diaphragm

Click to view Image

Endometriosis of peritoneum

underneath right ribcage

Click to view Image

Excised e ndometriosis of peritoneu

underneath right ribcage

Endometriosis and infertility!

Endometriosis is commonly associated with infertility. About 30% of women requiring IVF infertility treatment (in vit

fertilization or test tube babies ) have endometriosis. It is important to find out a bout endometriosis ea rly , so it c

be treated and infertility is

prevented or minimized.

Here are some of the previous photos w hich explain why a woman would not be able to become pregnant. When

anatomy is distorted, the tubes become blocked, the egg does not get picked up by the tube and cannot tr

through the tube to implant inside the uterus.

Click to view Image

Severe endometriosis. Complete obliteration of pouch of

Douglas. The bow el is densely adherent to ute rus, so only

top of uterus is visible. No normal anatomy of pouch of

Douglas is present.

Click to view Image

Severe endometriosis of vagina and pouch of Douglas.

Both ovaries are adherent to pelvic side wa lls.

Other diseases may be confused with endometriosis

Many women have irritable bowel disease w ith pain in the tummy, bloating, constipation and diarrhoea. The pain

be similar to endometriosis pain. Whilst pain gets better in the majority of women after endometriosis surg

sometimes s car tissue may form in the tummy which can cause pa in that can be similar to the pain of endometriosi

What endometriosis is NOT associated with

Endometriosis does not cause heavy or irregular periods. If a woman has lots o f bleeding with her periods, the do

will help her with that s eparately. The only menstrual irregularity endometriosis can cause is some spo t bleeding a

days before the proper periods start.

What about drug treatment?

The best drugs for period pain are tablets which are called non steroidal anti inflammatory drugs. These are

aspirin such as Ponstan, Nurufen, Naprogesic etc. They give better relief from period pain than paracetamol (Panad

Because not a ll period pain is from endometriosis, some women decide to try the oral contraceptive pill. The pill

by preventing ovulation (release of egg from the ovary) and stopping the large oestrogen surge from the ovary.

pill is usually given continuously by skipping the sugar tablets, so that there are no periods. This often cau

breakthrough bleeding where bleeding occurs at any time when the pill is taken. So realistically a woman need

have a prope r period on the pill every 3 to 4 months to stop that annoying bleeding.

A woman may decide to take the p ill for pain control rather than opt for a laparoscopy because a laparoscopy is an

operation with associated risks and she does not want to go down that path.

Studies have shown that after laparoscopic surgery for endometriosis, the disease may come back in about 30%

women. To minimize the recurrence of endometriosis, it is advised to commence hormonal treatment after surgery.

Mirena intrauterine device is often the best way to do that. It is highly effective in reducing the bleeding from per

or may even stop monthly periods and has very little side effects. Alternatively the pill may be given. For women

had severe endometriosis at surgery, she may be treated with a stronger drug called Zoladex for six months be

switching to the p ill or continuing with the Mirena.

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FIBROIDS

What are fibroids?

Fibroids are the most common benign (non-cancerous) growth of muscle and fibrous tissue that grow in the ute

and form a hard ball shaped mass.

Fibroids that grow inside the cavity of the uterus usually cause the most problems with heavy bleeding. Fortuna

they are also the ea siest to remove. Fibroids that are on the outside of the uterus, on the other hand, rarely cau

problem.

Fibroids shrink after the menopause when the ovaries stop producing the hormone oestrogen. Fibroids are m

common in obese and African women.

The possibility of cancer in a fibroid is very small. This occurs in only about 7 out of 1000 fibroids. This increases a

woman gets older and the risk doubles if a woman is postmenopausal. The small risk of cancer does not jus

surgery or a hysterectomy for all women with fibroids. However, unexplained rapid enlargement of a fib

particularly in a po stmenopausal woman, raises the possibility of cancer and surgery is needed.

What problems do fibroids cause?

There are three main problems fibroids can cause :

1. abnormal vaginal bleeding

Fibroids, especially those that are inside the cavity, can cause heavy periods or blee ding outside periods.

2. pressure on bladder or bowel

If a fibroid is large, it can press on the bladder and cause urgency to pass urine or discomfort when voiding. Pres

on the bowel can rarely cause constipation. A fibroid can also press on the ureter (tube that connects the kidney

the bladder) and cause obstruction to the kidney.

3. infertility & miscarriage

Large fibroids inside the uterine cavity can interfere w ith getting pregnant o r result in miscarriage.

4. pain

Fibroids are usually painless. Rarely when the blood going the fibroid is not enough for its size and growth, the ce

of the fibroid goes soft which then can cause pain.

5. abdominal mass

A fibroid may become so big to cause a large swelling in the tummy and a woman may look pregnant.

Do all fibroids need to be removed?

Most fibroids do not cause any problems to a woman and hence can be left alone. Your doctor will probably mon

growth of the fibroid(s) with a physical examination by your doctor and an ultrasound at a specified time, usually

12 months.

If a fibroid causes any of the above problems, treatment would be required.

Treatment

Treatment of fibroids depends on w hether the fibroids are causing any problems and whether a w oman wants to h

children or not. If childbearing is important, then a conservative approach is taken. The options are the following :
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Conservative management

Fibroids are not removed and a physical examination and / or ultrasound are done in 6-12 months to check for gro

It is important to note that fibroid surgery in itself can in some cases cause infertility because adhesions occur in

tummy and the tubes can become blocked.

Hysteroscopic resection

If the fibroid is inside the uterine cavity (submucosal), it can be removed by hysteroscopy as a day procedure. Ple

see section under hysteroscopy for further information. This involves inserting a telescope-like instrument f

between the legs into

the vagina and uterus. The fibroid is then cut out.

Myomectomy

This means the fibroid is cut out of the uterus and the uterus is left intact. This is done laparoscopically or with

open procedure, depending on the size and position of the fibroid(s). This would usually mean that deliverie

children would need to be done by caesa rean sections. The reason is that a scar would form in the uterus where a

was made to remove the fibroid(s) and there is a small risk of this scar opening up if the uterus was allowe

contract w ith normal labour pains.

Because cuts are made into the uterus, some bleeding occurs during the operation. A blood transfusion may

required and there is a small risk of needing a hysterectomy during a myomectomy to stop heavy bleeding.

Uterine artery embolization

This is a day procedure which is performed by interventional radiologists. They are doctors who specializ

ultrasounds, X-rays, CTs, MRI scans etc. Local anaesthetic is given in the groin and a very small cut is made in the s

A catheter (small tube) is then inserted into the femoral artery and fed upwards until the uterine artery is reac

The uterine artery is the blood vessel that gives blood to the uterus. The uterine arteries are then blocked of

putting a material in it. The fibroid(s) then also will not ge t any further blood and shrink. It is usually painful afterw

and women need admission to the ward for pain management.

Uterine artery embolization is associated with a 4% risk of ovarian failure. That means that in 4 out of 100 wom

who have this procedure done, the ovaries will stop functioning and early menopause will happen. Therefore

option is really only for women who have completed childbearing and are in their late forties and older.

Hysterectomy

Hysterectomymeans removal of the uterus. That means a woman will not have periods anymore and she will no

able to have any more children. Hysterectomy is therefore reserved for those women who have completed the ir fa

and despite more conservative treatments, continue to have problems from the fibroids. Hysterectomy is a g

option if fibroids are large and / or involve the cervix. The cervix is the ope ning part of the uterus which is at the to

the vagina. When a fibroid involves the cervix, it may not be possible to remove the fibroid and leave the ute

because of its position.

Fibroids & Pregnancy

It is not uncommon to be pregnant and have fibroids in the uterus because fibroids are so common. About 20%

fibroids enlarge during pregnancy, 20% decrease in size , and 60% remain unchanged.

Fibroids will never squash or de form a baby inside the uterus. Most pregnancies in the presence of fibroid will pro

without any problems.

Some of the problems a fibroid can cause with pregnancy and de livery are :

Pain

If a fibroid outgrows its blood supply, a part o f the fibroid dies and becomes soft. This can cause pain which is tre
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with non steroidal anti-inflammatory tablets such as Nurufen, Naprogesic, Brufen etc.

Breech or transverse lie of baby

If the fibroid is large enough and in the lower part of the uterus, the baby may not be lying head first but with

bottom first or lie sideways because they are better fits for the baby in the uterus.

Need for caesarean section

Again if the fibroid is large enough and in the lower part of the uterus, the cervix may not open up normally du

labour and the baby would need to be delivered by a caesarean section.

Bleeding after delivery of baby

Fibroids may prevent the ute rus to shrink after delivery of the baby, and bleeding can result. This may require a b

transfusion and further intervention to stop the bleeding.

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HEAVY MENSTRUAL BLEEDING

A woman"s menstrual flow is considered heavy if one o r more of the following is present:

1. Increase in the number of times pads or tampons that have to be changed (usually more frequent than every

hours or more than once a t night)

2. Bleeding that lasts more than seven days

3. Clots larger than three centimeters

4. Flooding (accidents where blood goes through a tampon or pad and onto clothes)

5. Anaemia (low iron count in the blood)

What are the causes of heavy menstrual bleeding?

Dysfunctional uterine bleeding

When w e cannot find a physical abnormality to account for the heavy menstrual bleeding, we say it is dysfunct

uterine bleeding. In a way this means we do not know exactly what the problem is but it is probably due to

subtle hormone changes. These hormone changes are so small they do not come up on the normal blood tests w

for hormones.

Fibroids

Fibroids are non-cancerous grow th inside the uterus which can cause heavy menstrual bleeding. Please have a loo

the section fibroids for further information.

Polyps
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very light or there is no bleeding at a ll. The Mirena can stay for five years and may be removed at any time before

if the woman wishes so.

A woman needs to know the following before she agrees to the Mirena :

There will be irregular vaginal bleeding for the first 3-6 months because tha t is the existing lining of the ut

coming away. Once the lining has become thin, this irregular bleeding stops and she will experience either

periods or no periods at a ll.

The Mirena is one of the most efficacious contraceptives. However, like all contraceptives, it has a failure r

Two in 1000 women who has the Mirena will get pregnant. Severe infection, miscarriage, premature delive

death o f the baby may occur if a woman becomes pregnant w ith the IUD. Therefore it is recommended thatMirena is removed which may cause a miscarriage.

There are side effects of the Mirena. Please have a look at the Mirena website at www.mirena-us.com

further information. Your doctor w ill discuss the possible s ide effects with you prior to its insertion.

Surgical treatment options of heavy menstrual bleeding

Endometrial ablation

At endometrial ablation the lining of the uterus is burnt with an instrument that is placed inside the uterine cavity.

done as a day procedure with a light anaesthetic (medication through the vein for sedation and local anaesthet

cervix).

Hysterectomy

Hysterectomy refers to the surgical removal of the uterus. Please have a look in the section hysterectomy for fur

information.

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ABNORMAL PAP SMEARS

What is a Pap smear?

A Pap smear is a screening test to see if abnormal changes are present in the cervix of the uterus. The cervix is

lowest part of the uterus which can be seen at the top of the vagina.

Your doctor inserts a speculum into the vagina so that the cervix can be visualized and a s craping of the cells fromcervix is taken with a little brush. The scrapings are then prepared on a microscope glas s slide and also placed in

vial of preparation fluid (Thin Prep). These are then sent to a pathologist who looks at the specimens und

microscope.

If the cells are abnormal, your GP or gynaecologist will explain the result to you. Dr Varol will also give you a pamp

for your reading. Abnormal cells are precancerous and some abnormalities may need treatment to be removed

cervical cancer doe s not develop.

Every women should have a routine Pap smear every two years, so precancerous abnormalities can be detected e

and treated , if necessary. Precancerous abnormalities usually do not cause any pa in or other physical symptoms,

Pap smear by your doctor is the only way to find out whether everything is ok or not.

What does the abnormality on my Pap smear mean?
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The important abnormality of the cells is called dysplasia which is not cancer, but can develop into cancer over a

but unpredictable period of time. Abnormalities on Pap smear are graded and classified as low or high grade.

precancerous changes involve only cells in the surface layer of the cervix.

Low & High Grade Abnormalities

Pap smear results are reported as low or high grade abnormalities, CIN (cervical intraepithelial neoplasia

dysplasia. Intraepithelial means within the tissue and neoplasia new growth of abnormal cells. They all desc

changes of the cervix which may develop into cancer. The more severe the abnormality, the less likely it is to go a

and the more likely it is to ge t worse and become cancer. So treatment is necessary for the more severe abnorma

to prevent cancer of the cervix from happening. The table below shows these terms.

Dysplasia Cervical intraepithelial Neoplasia

(CIN)

High/Low grade abnormality

Mild dysplasia CIN 1 low grade abnormality

Moderate dysplasia CIN 2 high grade abnormality

Severe dysplasia CIN 3 high grade abnormality

Atypia & Non-specific Minor Changes

These minor changes s een in a Pap smear are usually due to tissue inflammation, the human papilloma virus, or o

infections such as bacteria, yeast (thrush) etc. Usually this Pap smear goe s back to normal by itself and needs t

repeated in 12 months. It is very important that you come back for your Pap smear in 12 months.

If the abnormality persists, you will advised to have an examination called colposcopysee under heading colposc

Cervical Intraepithelial Neoplasia (CIN 1)

CIN 1 falls into the low grade abnormality category, whilst CIN 2 and 3 into the high grade group. In about 60%

women w ith CIN 1 this abnormality will disappear by itself. In the remaining 40%, CIN 1 will persist or become a hi

grade. Your doctor will advise you whether you just need another Pap smear in 6 months to see if the abnormality

gone, or you may need to have a colposcopyand b iopsy by your gynaecologist.

High-Grade Abnormalities

CIN 2 and 3

CIN 2 and 3 mean that the precancerous abnormalities are high grade. These abnormalities require treatmen

remove the abnormal cells. Depending on your doctor"s examination findings with the microscope (colposcopy)

the biopsy of the cervix, some women with CIN 2 may have the conservative option to repeat all the investigat

again in four to six months.

What is going to happen at the gynaecologist?

Colposcopy

If a minor abnormality persists with repeat Pap smears or if a high grade abnormality is present, an examination c

colposcopy is needed. The gynaecologist will insert a speculum into the vagina so the cervix can be seen. He/she

looks at the cervix with a colposcope which is a magnifying instrument similar to pair o f binoculars on a stand a

light attached. The colposcope itself does not enter the vagina. The cervix is then pa inted with a so lution called a

acid (dilute vinegar) and the doctor looks for abnormal cells.

This examination takes 10-15 minutes and is not a painful procedure. Some women experience discomfort from hav

the speculum in the vagina.


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Biopsy

Your doctor may need to take a very small sample of tissue from the abnormal part of the cervix. This is calle

biopsy. A special solution is then applied to the biopsy site to stop bleeding. You may experience some pai

discomfort similar to menstrual cramping. After the biopsy you may have slight vaginal bleeding and a vag

discharge for up to a week. Avoid vaginal intercourse, tampons, swimming and ba ths (shower instead) for a wee

allow the cervix to heal.

What causes abnormalities on Pap smear?

The precancerous abnormalities are caused by the Human Pap illoma Virus (HPV), also called wart virus, and cigar

smoking. HPV is similar to the virus which causes w arts on o ther parts of the body, such as the hands and feet. H

part of being s exually active and most men and women who are sexually active, do have HPV. In the vast majori

people, HPV infection is transient and harmless and the body"s immune system clears it within about two years.

So if the Pap smear just show s HPV only, then no further treatment is necessary. However, in some women persis

infection with some types o f HPV causes precancerous abnormalities on the cervix. The doctor would then recomm

a colposcopy and biopsy.

The tobacco in cigarettes has been shown to cause precancerous abnormalities on the cervix and cervical cancer.

a woman smokes and has an abnormal Pap smear, she should very seriously consider stopping smoking.

Will I need further treatment?

If the results of the colposcopy and cervical biopsy show a high grade abnormality, treatment is required to rem

the abnormal cells. There are several methods to remove the abnormal area o f the cervix which depends on the

and severity of the abnormal cells and the gynaecologist"s preference.

Wire Loop Excision

In this method, the abnormal cells are scooped from the cervix with a w ire loop.

A local anaesthetic is needed and the procedure takes 15 to 30 minutes and is performed in a day procedure cen

doctor"s surgery or hospital outpatient de partment. A bloody brown, o r black discharge w ill be present for up to

weeks after the procedure. Some mild tummy cramps or pain may persist for a day or two afterwards as well. M

women can return to work within two or three days after the procedure.

The abnormal part of the cervix that has been removed is then sent to the pathologist

who :

confirms whether all the abnormal cells have been removed, and

determine the type o f abnormality present.

Laser

The abnormal cells are de stroyed using heat from a laser beam which is an intense, highly focused beam of specia

light). Again this procedure is pe rformed in a day procedure centre, doctor"s surgery or hospital outpatient

department.

Cone biopsy

For a cone biopsy a cone-shaped section of the cervix containing the abnormal cells is removed.


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This usually requires a general anaesthetic and a day hospital stay. A cone biopsy is donewhen :

Pap smear show ed abnormal changes in the glands of the cervix

abnormal cells go up in the cervical canal

to exclude cervical cancer.

Will treatment affect my chances of becoming pregnant?

No, treatment does not cause infertility. However, there is a slightly increased risk of cervical incompetence wit

cone biopsy and loop excision. Cervical incompetence means that the cervix does not stay closed during pregna

and can open up, resulting in a miscarriage in the mid trimester o f pregnancy, that is, between about 3 to 6 mont

pregnancy. If it is recognized in time, the obstetrician would place a stitch into the cervix under a general anae st

in the operating thea tre. The stitch is removed when it is time to de liver the baby.

Another complication can occur called cervical stenosis. This means scar tissue has formed in the cervix and it

become closed off. Menstrual fluid cannot flow into the vagina and tummy pain may occur. The gynaecologist w

need to d ilate the cervix in the operating theatre under a light anaesthetic.

What are the potential complications of treatment?

Following treatment to remove the abnormal cells of the cervix, bleeding and infection may occur. This may req

antibiotics through a drip in the arm and admission in hospital. For the bleeding the doctor may place a tissue

into the vagina to keep pressure on the cervix for about 24 hours. Alternatively a suture may be needed in the c

in the operating theatre.

Cervical incompetence and stenosis have bee n explained above.

What follow-up do I need to have?

Follow-up depends on the abno rmality and your doctor will formulate a plan with you. You may need to come ba

six or 12 months for a low grade abnormality. Following trea tment for a high grade abnormality, follow-up is usua

four to six monthly intervals initially, then yearly until two consecutive Pap smears, colposcopy and HPV tests

negative (normal).

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Case Adnexa Endometriosis

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