Vaginale Blutungen vor der Menopause bei gynäkologischen Malignomen

The incidence of gynaecological malignancies in pre-menopausal patients varies with age. Cervical cancer is most common in younger, premenopausal patients reaching its peak between the ages of 35 and 39 years. Vaginal carcinoma is very uncommon. Vaginal discharge and abnormal bleeding during the pre-menopause period are often the result of a clinically invasive or advanced vaginal or cervical cancer. A maximum of 25% of patients with endometrial cancer are younger than 25 years, and less than 5% are younger than 40 years. In the case of ultasonographically abnormal endometrial tissue and irregular menstrual cycles, a dilatation and curettage is necessary. The diagnosis of endometrial cancer is often based of the finding of atypical hyperplasia of the endometrium. In pre-menopausal patients about 3–7% of ovarian tumors are malignant. Abnormal menstrual bleeding may occur in patients with epithelial ovarian cancer or hormone secreting tumors of the ovary. All malign genital diseases may be responsible for abnormal vaginal bleeding or disorders of menstrual cycle. For this reason, clinical examination, including coloscopy and ultrasound of uterus and appendages, is necessary to rule out a malignancy. Vaginal bleeding after birth or abortion with increased β-HCG levels may be the result of remaining trophoblast tissue and dilatation and curettage are necessary. Curettage also eliminates the possibility of choriocarcinoma.     

Vaginale Geburt

Postpartal stress incontinence occurs in 0.7–35% of cases. Approximately 10% of women have persistent symptoms of anorectal incontinence. A third-degree perineal tear leads to incontinence problems in 20–50% of cases. Individual constitution of the connective tissue, further vaginal deliveries and age of the patient determine the risk of deterioration. An episiotomy does not reduce the occurrence of either incontinence or genital prolapse. Greater perineal damage occurs more often after episiotomy than with no episiotomy. We should therefore consider a very strict policy regarding episiotomy in the future. Patients with symptoms of pelvic floor weakness or insufficiency should be thoroughly examined and informed before any further pregnancies or deliveries are undertaken. Forty percent of women with occult anal sphincter lesions will develop an anal weakness after delivery of a second child. Forceps delivery is the most traumatic mode of delivery for the mother. The significance of an epidural anaesthetic has not yet been clarified. In the literature, the trend is toward recommending antenatal consultation regarding elective cesarian section in cases of pelvic floor insufficiency.     

Vaginale Kontrazeption

Dosage and indications

The vaginal rings NuvaRing® and Circlet® are combination hormonal preparations which emit 15 µg ethinyl estradiol and 120 µg etonogestrel daily. The dosages are therefore very low. These vaginal rings are combination products which are applicable for any woman of any age and are not niche products for special indications.

Handling and safety

The handling and insertion of the ring into the vagina and removal are simple. A negative impact on sexual behavior and experience are not to be expected. Because of the very low continuously delivered dose of ethinyl estradiol, substantially less additional bleeding occurs than with oral combination products. Other advantages of the vaginal ring are very good Pearl index and the high acceptability and compliance.     

Vaginale Candidose

Colonization of the vagina with Candida spp. does not necessarily induce an inflammatory response. The most frequent pathogens are Candida albicans followed by C. glabrata. Pathogenesis is dependant on the virulence of the yeast, individual predisposition as well as on the host’s defense system. Women aged from 15 to 45 years — especially when pregnant or under hormonal contraception — are particularly susceptible to vaginal mycosis. Indeed, yeasts possess estrogen receptors, making them more virulent when estrogen is present. Local innate immunity is crucial for infection, while humoral immunity is of minor importance. Cellular immunity, however, is essential, although the cooperation between the different components is not well understood. Therapy consists either of the local application of diverse antiseptics or of antimycotics, or in the use of systemically active antimycotics such as fluconazole. In case of recurrent infections, a secondary prophylaxis with fluconazole is recommended.     

Vaginale und abdominale Hysterektomie

Hysterectomy is one of the most common major gynecological operations. There are several different techniques for performing it, and if it is indicated, the appropriate operative approach, vaginal or abdominal, must be chosen. The advantages and disadvantages of the two approaches, the uterine size and mobility, previous operations, the surgeon’s experience, and the local operating conditions should all be considered. Vaginal hysterectomy has advantages compared with abdominal hysterectomy: The operating time is shorter, it is safer, and the hospital stay and recovery time are shorter as well. Therefore, a vaginal approach should be preferred in patients with benign diseases. Vaginal uterine extirpation is the first operative choice in patients with uterus myomatosus and dysfunctional uterine bleeding. The integration of new technical possibilities, such as bipolar coagulation forceps, has improved haemostasis and produces less blood loss and less postoperative pain.     

Vaginale Deszensuschirurgie mit Gewebeersatz

Vaginal mesh surgery is both innovative and controversial. It has been proven that transvaginal access, reduction of mesh weight and inert coatings reduce mesh-specific complications so that patients profit from the use of vaginal meshes particularly in recurrent prolapse situations. Extended indications were therefore discussed and have already been clinically implemented. The critical discussion on vaginal mesh surgery means that more scientific data are being recruited, more expertise is being incorporated into operative implementation and affected patients are being more actively included in decision-making for or against the use of vaginal meshes. The sometimes too emotional assessment of vaginal mesh surgery occasionally diminishes a reasonable implementation and often leads to insufficiently indicated revision operations and complete mesh removal under conditions with questionable legal consequences. This article describes the current situation for prolapse surgery with tissue replacement and takes a critical stance from a scientific and especially clinical perspective.     

Postpartale Blutungen

Zum Thema Schwere postpartale Blutungen k?nnen auch heute noch zu lebensbedrohlichen Situationen führen. In den L?ndern der 3. Welt sind sie eine der h?ufigsten Todesursachen in der Gravidit?t. H?ufigste Ausl?ser früher postpartaler Blutungen sind die Uterusatonie, Verletzungen der Geburtswege und unvollst?ndige Plazenta. Prim?re Gerinnungsst?rungen als Ursache sind eher selten. Wohl aber kann es infolge einer postpartalen Blutung zu einer lebensbedrohlichen Verbrauchskoagulopathie kommen. Für sp?te Blutungen im Wochenbett sind meist Infektionen oder unerkannt gebliebene Plazentareste verantwortlich. Die in der Gravidit?t physiologische Hyder?mie kann einen postpartalen Blutverlust lange Zeit kompensieren. Ein hypovol?mischer Schock tritt dann aber ziemlich schlagartig auf. Wichtig ist deshalb die frühzeitige klinische Diagnose. Zu denken ist auch an eine Plazenta accreta oder increta, die eventuell auch eine Hysterektomie erforderlich machen kann. Ursache einer bedrohlichen Nachblutung nach Abschlu? der Plazentarperiode ist in 90 % eine Uterusatonie. Das Handling und die Nebenwirkungen einer Atoniebehandlung werden dargestellt. Wenn alle medikament?sen Therapien versagen ist die chirurgische Intervention angezeigt. Auch Verletzungen der Geburtswege – z. B. bei operativen Vaginalentbindungen, BE-Lagen, Schulterdystokie, hohem Cervix- und/oder Vaginalri?– müssen bei verst?rkten postpartalen Blutungen in die überlegungen einbezogen werden. Nicht vergessen werden darf die Uterusruptur, deren übersehen lebensgef?hrlich ist. Zur Abkl?rung unklarer Blutungen im Wochenbett hilft die Sonographie weiter. H?ufig handelt es sich um Plazentarpolypen, die eine Curettage erfordern.     

Diagnose uteriner Blutungen

Abnormal uterine bleeding is a gynecological problem frequently seen in women from adolescence to the postmenopausal period. Nearly 70% of patients' visits to the gynecologist in the peri- and postmenopausal period are due to abnormal uterine bleeding. Diagnostic procedures in the gynecologist's office differ greatly and depend on the reproductive age of the individual patient. It is very important to have precisely specified the type of bleeding disorder and in premenopausal patients to differentiate between ovulatory and anovulatory cycles after excluding pregnancy. Taking a family history may provide information about familial coagulation disorders. Laboratory studies should include a pregnancy test and possibly a diagnosis of any hormonal disorders. For decades the standard diagnostic procedure to distinguish between normal and pathological endometrium was dilatation and curretage. Various studies, however, have cast doubt on the reliability of this method since curettage only reached less than half of the uterine cavity in 60% of cases and after hysterectomy endometrial carcinoma had not been diagnosed in 15% of cases by dilatation and curretage. The preferred diagnostic method in abnormal uterine bleeding is 5-mm hysteroscopy. With this method the whole uterine cavity can be visualized. In combination with a targeted biopsy, almost 100% rates of sensitivity and specificity can be achieved. In particular, intrauterine polyps and submucosal myomas, which are often missed with dilatation and curretage, can be diagnosed with certainty by hysteroscopy. Diagnostic hysteroscopy involves virtually no complications and can be performed on an outpatient basis in 94% of cases. Thanks to further improvements in the optics and reductions in the shaft diameter, the “mini-hysteroscope,” a flexible 2.4-mm optic, was developed, making dilatation of the cervical canal and any form of anesthetic unnecessary in 98% of cases. Transvaginal sonography has proven to be a good means of screening to distinguish between normal and pathological endometrium. For such indications, it shows a 96% sensitivity and 86% specificity in premenopausal patients with respect to hysteroscopic findings. Intrauterine changes cannot be differentiated with certainty on sonography and so any if there are any unusual findings, hysteroscopy should always be performed. Although some authors are in favor of sonohysterography, it has not yet gained clinical acceptance everywhere in Germany. By instilling saline solution in the uterine cavity a similarly high sensitivity in differentiating between myomas and polyps can be reached as with hysteroscopy; however, specificity is lower.     

Blutungen in der Postmenopause

There is no functional bleeding in postmenopausal women. Therefore every postmenopausal bleeding requires an appropriate gynecological investigation. Etiology may include endometrial hyperplasia, cervical cancer, or endometrial malignancy. Even a bleeding under HRT is possible. This review describes the causes of vaginal bleeding and the appropriate diagnostic procedures.     

Vorgehen bei plazentaren Blutungen

Peripartum hemorrhage is associated with a high maternal and fetal morbidity and mortality and is one of the leading causes of maternal death worldwide (25%). The major causes of hemorrhage are placenta previa, premature abruption of the placenta and uterine atony. In cases with placental abruption or bleeding from the vasa previa there is an extremely high risk for the fetus as well as for the mother. The diagnosis of hemorrhage is suspected from the clinical manifestations and confirmed by ultrasonography. The prognosis for both mother and child can be markedly improved if the risk factors for hemorrhage are recognized early and the problem is treated rapidly and appropriately.     

Vaginale Keimbesiedelung in Korrelation zu hormonstatus und zervixzytologie

Zusammenfassung 46,7% der Patientinnen zeigten pathologische Erreger im Vaginalabstrich. Oft bestanden gleichzeitig St?rungen im Hormonhaushalt. Bei zytologischen Ver?nderungen fanden sich h?ufiger pathologische Keime. Erreger wie B-Streptokokken, Gardnerella vaginalis und Chlamydien sollten konsequent, ggf. unter Einbeziehung des Partners, behandelt werden.