Screening for gynaecological conditions

Screening is one of the most often discussed areas of gynaecology today. In this chapter, after a brief review of WHO criteria for a screening programme and relevant statistical terms, the pros and cons of screening are considered. Its role in gynaecological cancers, genetic conditions and chlamydial infection is discussed. Ultrasound and multimodal screening can detect ovarian cancer in asymptomatic women, but there is insufficient evidence on whether screening improves outcome including mortality for women in any risk group. BRCA 1 and 2 screening is offered to women with families in which two or more first-degree relatives are affected by ovarian or premenopausal breast cancer. This gives a 65% chance of identifying a mutation. We have considered some of the interesting developments in cervical screening like PAPNET, thin prep and HPV testing. After discussing some of the controversies in breast cancer screening programmes, the case for introduction of chlamydia screening is debated.     

Screening for gynaecological conditions

Well-organised cervical screening programmes have reduced the mortality from cervical cancer by up to 50% in the developed world. Despite the successful development of human papilloma virus vaccines, there is likely to remain a need for cervical screening for the foreseeable future. In contrast, the value of mass screening for ovarian cancer remains unproven, although current screening methods can detect early-stage disease in asymptomatic individuals. Breast screening does appear to be associated with a reduction in mortality in the long term but paradoxically may increase death rates in young women in the short term. Testing for sexually transmitted infections is effective in reducing morbidity but tends to be selective at present because of concerns over the cost and psychosocial implications of general population screening.     

Imaging malignant gynaecological conditions

Radiology continues to play an essential role in the management of malignant gynaecological conditions. Multiple imaging modalities are utilised to investigate suspected gynaecological malignancy including: ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. Each modality has a different role in diagnosis, staging, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging of malignant gynaecological disease. The imaging findings of common female pelvic pathology are discussed and illustrated.     

Imaging malignant gynaecological conditions

Radiology plays an essential role in the management of malignant gynaecological conditions. Multiple imaging modalities are utilized to investigate suspected gynaecological malignancy including: ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. Each modality has a different role in diagnosis, staging, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging of malignant gynaecological disease. The imaging findings of common female pelvic pathology are discussed and illustrated.     

Imaging benign gynaecological conditions

Radiology plays an essential role in the management of benign gynaecological conditions and includes: ultrasound; computed tomography and magnetic resonance imaging. Each modality has a different role in diagnosis, treatment selection and follow-up. This review discusses the different imaging modalities, their recommended roles in the imaging and imaging findings of common female pelvic pathology.     

Imaging benign gynaecological conditions

Radiology continues to play an essential role in the management of benign gynaecological conditions. Multiple imaging modalities are utilised to investigate benign conditions: ultrasound; computed tomography and magnetic resonance imaging. Each modality has a different role in diagnosis, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging benign gynaecological conditions. The imaging findings of common benign female pelvic pathology are discussed and illustrated.     

Screening and prevention of gynaecological cancer

Environmental factors have a huge impact on the development of gynaecological cancers. Avoidance of tobacco and of unsafe sex, adherence to a balanced diet rich in fruit and vegetables, moderate exercise and use of the oral contraceptive will all substantially reduce a woman’s risk. Regular Pap smear screening is very protective against the subsequent development of cancer of the cervix but unfortunately, screening tests for endometrial and ovarian cancers are currently not available.     

Pathological conditions predisposing to infertility and gynaecological neoplasia

Some of the conditions long blamed for female factor infertility are now acknowledged as well established risk factors of gynecological neoplasia. This realization has lead to the proposition that infertility might be a risk factor for the development of several types of gynecological neoplasms. This review addresses different conditions that play a role in both infertility and gynaecological neoplasia. An intricate interplay between growth factors and hormonal factors (estrogens and progestins, androgens and gonadotropins) is said to link the state of infertility to some gynecological tumors. The relation between endometriosis -as one of the well established causes of female infertility - and ovarian cancer is well known. Endometriosis has been particularly related to endometrioid and clear-cell ovarian carcinomas. Another evidence for this association is embodied in finding endometriotic lesions adjacent to ovarian cancers. The polycystic ovary syndrome (PCOS), one of the most prevalent endocrine disorders and a long studied cause of female infertility increases the risk of endometrial carcinoma. The link between PCOS and endometrial carcinoma seems to be endometrial hyperplasia. PCOS-associated endometrial carcinoma tends to present at a younger age and early stage, with lower grade and lower risk of metastasis. Turner’s syndrome and other types of ovarian dysgenesis constitute a rare cause of infertility and are known to confer a definite risk of germ cell tumors. There seems to be a link between infertility and an increased risk of gynecological neoplasia. Hence, it is important to assess the risk of malignancy in each category of infertile patients so as to provide optimal and timely intervention.     

Comparison of serum anti-Mullerian hormone levels following hysterectomy and myomectomy for benign gynaecological conditions

Objective

To compare serum anti-Mullerian hormone (AMH) levels following hysterectomy and myomectomy.

Study design

Prospective longitudinal observational study. Serum AMH, follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels were measured pre-operatively (T1) and 2 days (T2) and 3 months (T3) following hysterectomy and myomectomy in 70 women aged 36–45 years. Hysterectomy (laparoscopy-assisted vaginal hysterectomy = 10; total abdominal hysterectomy = 25) with conservation of both ovaries for benign diseases of the uterus was performed in 35 women, and myomectomy (laparoscopy myomectomy = 15; open myomectomy = 20) was performed in another 35 women. The follow-up period was 3 months following surgery. The results were analysed using the t-test or one-way analysis of variance by repeated-measures ANOVA.

Results

Serum AMH in the hysterectomy group was 1.08 ± 0.77 ng/ml at T1, 0.78 ± 0.58 ng/ml at T2 and 0.81 ± 0.58 ng/ml at T3; the level was significantly lower at T2 and T3 compared with T1. In the myomectomy group, the corresponding values were 1.54 ± 0.95 ng/ml, 1.18 ± 0.77 ng/ml and 1.50 ± 0.58 ng/ml; serum AMH was significantly lower at T2 compared with T1, but the difference between T3 and T1 was not significant. There were no significant differences in serum FSH and LH in either group between these three time points.

Conclusion

Serum AMH was significantly lower 2 days and 3 months following hysterectomy compared with the pre-operative level. Following myomectomy, serum AMH was significantly lower than the pre-operative level 2 days following the procedure, but was similar to the pre-operative level 3 months after surgery. Therefore, hysterectomy may have a more lasting adverse effect on ovarian reserve than myomectomy. A long-term study of AMH levels is needed.     

Treatments for gynaecological cancers

Gynaecological cancers account for a significant amount of morbidity and mortality in the world, with varying incidences and outcomes depending on the country. These malignancies consist of vulval, vaginal, cervical, endometrial, fallopian and ovarian cancers, and account for between 10 and 15% of women's cancers. Although mainly a disease of post-menopausal women, when affecting younger women, fertility-related consequences exist. Therapeutic interventions for gynaecological cancers include surgery, chemotherapy and radiotherapy, with combination modalities often required. The basis for certain therapies are derived from appropriately conducted randomized clinical trial, whereas in some settings, therapy is based on clinical experience and intuition. This review will endeavour to focus on the evidence base, though inevitably, non-evidence based practice is unavoidable.     

Screening for common clinical conditions in older women

The prevalence of diabetes mellitus, dyslipidemia, hypertension, and thyroid disease is higher in older women, placing these women at increased risk of cardiovascular disease. The presenting features of these conditions are most often clinically silent. Effective treatments for these conditions are available to prevent cardiovascular disease morbidity and mortality. An overview of current screening guidelines for these common conditions is presented.     

Hysterectomy for benign gynaecological disease

Despite the advent of newer, and in some instances less invasive, interventions for the management of abnormal uterine bleeding, hysterectomy remains the most commonly performed major gynaecological operation. It continues to score highest in satisfaction rates. It is therefore imperative that all aspects of this operation are reviewed on a regular basis. For example, all evidence suggests that the vaginal route is the safest, most cost-effective approach affording rapid recovery, yet the majority of hysterectomies are still performed by the abdominal route. Newer approaches such as robotic surgery have captured the imagination of the enthusiasts, yet this approach is hugely expensive, and there are no data justifying its use over the laparoscopic or indeed the conventional approach. Quality of life should remain the principal outcome measure for hysterectomy for benign disease, and therefore the impact of the various approaches to hysterectomy should address this outcome. Complications of any new approach should be addressed, and the question that continues to elude an answer, namely why there are such widely and wildly varying rates of hysterectomy between surgeons in one hospital, between hospitals in one region, between the regions and between countries, should continue to be addressed, and perhaps one day the definitive study that will answer the question will be undertaken.     

Community-based post-operative follow-up visit after major surgery for benign gynaecological conditions: a prospective study.

The time from surgery to discharge after major procedures for benign gynaecological conditions continues to fall. This small prospective study was undertaken to assess the postoperative problems encountered by patients after gynaecological surgery for a variety of benign disorders, and the potential of the 6-week surgical follow-up to be performed by the patient's family doctor rather than the hospital. The patients' and doctors' satisfaction with such care was determined. The study showed that follow-up in the community was acceptable to both patient and doctor. When problems arose after discharge most patients ( 50%) contacted their family doctor. At the 6-week visit few had physical problems, though most (58-100% depending on the Group) felt that a 6-week follow-up was required. Six-week postoperative follow-up by the family doctor is acceptable, and could permit more effective use of hospital specialists, though would increase the workload of family doctors.     

Laparoscopic surgery for gynaecological oncology

PURPOSE OF REVIEW: The use of laparoscopic staging and/or surgery in the field of gynaecological oncology was pioneered in the early 1990s. The issue has been very controversial from the beginning, with some justification in view of the possible consequences of faulty cancer surgery. After more than 10 years, long-term follow-up and comparative studies, both of which are required in clinical oncological research, are now available. RECENT FINDINGS: A number of papers have confirmed the absence of significant adverse effects on survival after laparoscopic diagnosis or surgery in gynaecological cancers. New developments cover virtually all the basic techniques in cancer surgery, excluding major exenterative surgery. The use of an extraperitoneal technique for aortic dissections is emerging. New indications, such as radical vaginal trachelectomy, pelvic sentinel node identification, interval debulking surgery of adnexal malignancies, or the liberal use of surgical staging of uterine cancers, have been developed as a direct result of the availability of laparoscopic techniques. SUMMARY: Continuing worldwide interest clearly demonstrates that laparoscopic techniques are now part of the armamentarium of the gynaecological oncologist. Postoperative morbidity and recurrence risk do not seem to be affected. Cost-efficiency of laparoscopic procedures is based on the reduction of hospital stay. Combined training in gynaecological oncology and in laparoscopic surgery is, more than ever, mandatory as a means of avoiding the risk of inadequate staging or the mismanagement of pelvic malignancies. The diversity of techniques, including laparotomy, laparoscopy, and vaginal surgery, allows the individualization of surgical approaches, whereby tumour size and local or general conditions can be taken into account.     

Genetic testing for gynaecological cancer

The traditional family-history approach to genetic testing involves taking a detailed three generation family-history from both sides of the family, ethnicity, type of cancer, age of onset and death. Testing for BRCA1/BRCA2 mutations is offered at a ≥10% combined BRCA1/BRCA2 probability. Risk models such as the Manchester scoring system, BOADICEA and BRCAPRO can be used to calculate BRCA1/BRCA2 probability. High-risk women identified should be referred to a regional genetics service for genetic counselling and testing. The Amsterdam-Criteria-2 have been traditionally used to identify Lynch syndrome (caused by a mismatch repair gene (MLH1/MSH2/MSH6/PMS2) mutation). Molecular (immunohistochemistry and Microsatellite instability) analysis of tumour tissue is now established as an initial step, with genetic testing undertaken for protein deficient or MSI unstable tumours. This is offered for those fulfilling Bethesda criteria and recently for all colorectal cancer cases <60 years. BRCA1/BRCA2 testing is recommended for all non-mucinous invasive epithelial ovarian cancers irrespective of family-history (10–20% have a BRCA1/BRCA2 mutation). This is being undertaken by non-genetics clinicians. A population-based approach to genetic testing identifies 50% more carriers at risk. It has been extensively investigated in the Ashkenazi-Jewish population and found to be extremely cost-effective in this community. This is expected to lead to change in guidelines in the future.     

Psychometric properties of the Body Image Scale in women with benign gynaecological conditions

Objectives: To evaluate the psychometric properties of the Body Image Scale (originally designed for use in cancer) in women with benign gynaecological conditions. STUDY DESIGN: Prospective completion of the Body Image Scale by women participating in the EVALUATE Hysterectomy Trial. The scale was completed pre-operatively, then 6 weeks, 4 and 12 months post-operatively. The psychometric properties were evaluated by assessing the reliability, response prevalence, discriminant validity and sensitivity to change. Factor analysis was also conducted to determine the scale structure. RESULTS: The Body Image Scale showed good reliability and clinical validity. Differences between sub-groups of women were detected, demonstrating good discriminant validity. The Body Image Scale was shown to be responsive to changes in body image. CONCLUSIONS: The Body Image Scale was shown to be a reliable and valid tool for assessing body image in women with benign gynaecological conditions and for use in clinical trials involving such women.