OBSTETRICS AND GYNECOLOGY

GYNECOLOGY

Cervical Dysplasia

Cervical dysplasia is a precancerous condition in which abnormal cell growth occurs on the surface lining of the cervix or endocervical canal, the opening between the uterus and the vagina. It is also called cervical intraepithelial neoplasia (CIN). Strongly associated with sexually transmitted human papillomavirus (HPV) infection, cervical dysplasia is most common in women under age 30 but can develop at any age.

Cervical dysplasia usually causes no symptoms, and is most often discovered by a routine Pap test. The prognosis is excellent for women with cervical dysplasia who receive appropriate follow-up and treatment. But women who go undiagnosed or who don’t receive appropriate care are at higher risk of developing cervical cancer.

Mild cervical dysplasia sometimes resolves without treatment, and may only require careful observation with Pap tests every three or six months. But moderate-to-severe cervical dysplasia — and mild cervical dysplasia that persists for two years — usually requires treatment to remove the abnormal cells and reduce the risk of cervical cancer.

Diagnosis of Cervical Dysplasia

Because a pelvic exam is usually normal in women with cervical dysplasia, a Pap test is necessary to diagnose the condition.

Although a Pap test alone can identify mild, moderate, or severe cervical dysplasia, further tests are often required to determine appropriate follow-up and treatment. These include:

Repeat Pap tests

Colposcopy, a magnified exam of the cervix to detect abnormal cells so that biopsies can be taken. Endocervical curettage, a procedure to check for abnormal cells in the cervical canalCone biopsy or loop electrosurgical excision procedure (LEEP), which are performed to rule out invasive cancer; during a cone biopsy, the doctor removes a cone-shaped piece of tissue for lab examination. During LEEP, the doctor cuts out abnormal tissue with a thin, low-voltage electrified wire loop.

HPV DNA test, which can identify the HPV strains which are known to cause cervical cancer.

Treatments for Cervical Dysplasia

The treatment of cervical dysplasia depends on many different factors, including the severity of the condition and the age of the patient. For mild cervical dysplasia, often only continued monitoring with repeat Pap tests is needed. For older women with mild cervical dysplasia, usually no treatment is needed unless mild cervical dysplasia has persisted for two years, progressed to moderate or severe cervical dysplasia, or there are other medical problems.

Treatments for cervical dysplasia include two of the procedures also used for diagnosis: cone biopsy or LEEP.

Other treatments include:

  • Cryosurgery (freezing)
  • Electrocauterization
  • Laser surgery

Because all forms of treatment are associated with risks such as heavy bleeding and possible complications affecting pregnancy, it’s important for patients to discuss these risks with their doctor prior to treatment. After treatment, all patients require follow-up testing, which may involve repeat Pap tests in six and 12 months or an HPV DNA test. After follow-up, regular Pap tests are necessary.

Chorionic Villus Sampling

Doctor may suggest CVS if the baby has a higher risk of some birth defects. That could be if the patient is over 35, have a family history of problems, or had unusual results after the first-trimester screening.

CVS is an alternative to amniocentesis. Like amniocentesis, CVS can diagnose some disorders. It checks the baby’s chromosomes for birth defects or genetic disorders. Doctor takes a sample of cells from the placenta. Then a lab tests the cells to analyze the baby’s chromosomes. The lab tests can include the karyotype test, the FISH test, and microarray analysis.

CVS helps rule out some birth defects, such as Down syndrome, Tay-Sachs disease, cystic fibrosis, sickle cell anemia, and others.

The advantage of CVS is that can get this test five to 10 weeks earlier than amniocentesis. The disadvantage is that it can’t detect neural tube defects, such as spina bifida.

CVS is relatively safe. But it is an invasive procedure, and it poses a risk of miscarriage slightly higher than amniocentesis. It also poses a small risk of complications in the baby, such as loss of limbs.the test has to be done by doctor who has a lot of experience doing CVS.

Doctors do the CVS test two different ways. Using ultrasound to guide the way, the doctor may insert a small needle into the belly to take a sample of cells from the placenta. Or, doctor may insert a thin plastic tube through the vagina to get a sample from the placenta. The test can be uncomfortable, but only lasts about 10 minutes.

Should get test results in about one week. CVS is very accurate. If the baby does have a problem, can meet with a genetic counselor and talk about the options.

Test Is Done During Pregnancy just once, doctor will suggest it when the patient are 10 to 13 weeks pregnant.

Ventrosuspension

As many as 20% of women have a so-called retroverted uterus in which the uterus is tilted backwards instead of forwards (anteverted)

For most patients, a retroverted uterus is natural, and most patients experience no symptoms or problems during normal life or pregnancy related to the retroverted uterus. However, some patients with a retroverted uterus experience chronic pelvic pain, dyspareunia (pain during sexual intercourse) and dysmenorrhea (pain during menstruation). It has been shown that correction of uterus retroversion by surgery can reduce or eliminate these symptoms. It is important to note uterus retroversion is not believed to itself influence fertility, however other pelvic pathologies such as endometriosis and fibroids can be the cause of both a retroverted uterus and infertility; it is therefore being necessary to treat the underlying conditions (such as the endometriosis or fibroids) to improve fertility, not the retroverted uterus itself. Thus, correction of a retroverted uterus is required to improve pain associated with retroversion but not fertility.

Correction of a retroverted uterus is completed via a surgical technique, ventrosuspension. During ventrosuspension, the retroverted uterus is moved into an anteverted position by shortening the ligaments (“round ligaments”) which hold the uterus in position by attaching them to the abdominal wall.

Hysteroscopy

Hysteroscopy is a procedure that allows the doctor to look inside the uterus in order to diagnose and treat causes of abnormal bleeding. Hysteroscopy is done using a hysteroscope, a thin, lighted tube that is inserted into the vagina to examine the cervix and inside of the uterus. Hysteroscopy can be either diagnostic or operative.

Diagnostic hysteroscopy is used to diagnose problems of the uterus. Diagnostic hysteroscopy is also used to confirm results of other tests, such as hysterosalpingography (HSG). HSG is an X-ray dye test used to check the uterus and fallopian tubes. Diagnostic hysteroscopy can many times be done in an office setting.

Additionally, hysteroscopy can be used with other procedures, such as laparoscopy, or before procedures such as dilation and curettage (D&C). In laparoscopy, the doctor will insert an endoscope (a slender tube fitted with a fiber optic camera) into the abdomen to view the outside of the uterus, ovaries and fallopian tubes. The endoscope is inserted through an incision made through or below the navel.

Operative hysteroscopy is used to correct an abnormal condition that has been detected during a diagnostic hysteroscopy. If an abnormal condition was detected during the diagnostic hysteroscopy, an operative hysteroscopy can often be performed at the same time, avoiding the need for a second surgery. During operative hysteroscopy, small instruments used to correct the condition are inserted through the hysteroscope.

Doctor may perform hysteroscopy to correct the following uterine conditions:

  • Polyps and fibroids — Hysteroscopy is used to remove these non-cancerous growths found in the uterus.
  • Adhesions — Also known as Asherman’s Syndrome, uterine adhesions are bands of scar tissue that can form in the uterus and may lead to changes in menstrual flow as well as infertility. Hysteroscopy can help doctor locate and remove the adhesions.
  • Septums — Hysteroscopy can help determine whether patients have a uterine septum, a malformation of the uterus that is present from birth.
  • Abnormal bleeding — Hysteroscopy can help identify the cause of heavy or lengthy menstrual flow, as well as bleeding between periods or after menopause. Endometrial ablation is one procedure in which the hysteroscope, along with other instruments, is used to destroy the uterine lining to treat some causes of heavy bleeding.

Colporhaphy

Colporrhaphy is the surgical repair of a defect in the vaginal wall, including a cystocele (when the bladder protrudes into the vagina) and a rectocele (when the rectum protrudes into the vagina).
A prolapse occurs when an organ falls or sinks out of its normal anatomical place. The pelvic organs normally have tissue (muscle, ligaments, etc.) holding them in place.

Factors that are linked to pelvic organ prolapse include age, repeated childbirth, hormone deficiency, ongoing physical activity, and prior hysterectomy. Symptoms of pelvic organ prolapse include stress incontinence (inadvertent leakage of urine with physical activity), a vaginal bulge, painful sexual intercourse, back pain, and difficult urination or bowel movements.

Colporrhaphy may be performed on the anterior (front) and/or posterior (back) walls of the vagina. An anterior colporrhaphy treats a cystocele or urethrocele, while a posterior colporrhaphy treats a rectocele. Surgery is generally not performed unless the symptoms of the prolapse have begun to interfere with daily life.

The patient is first given general, regional, or local anesthesia. A speculum is inserted into the vagina to hold it open during the procedure. An incision is made into the vaginal skin and the defect in the underlying fascia is identified. The vaginal skin is separated from the fascia and the defect is folded over and sutured (stitched). Any excess vaginal skin is removed and the incision is closed with stitches.

Abdominal Hysterectomy

An abdominal hysterectomy is a surgical procedure that removes uterus through an incision in lower abdomen. Uterus — or womb — is where a baby grows if pregnant. A partial hysterectomy removes just the uterus, leaving the cervix intact. A total hysterectomy removes the uterus and the cervix.

Sometimes a hysterectomy includes removal of one or both ovaries and fallopian tubes, a procedure called a total hysterectomy with salpingo-oophorectomy (sal-ping-go-o-of-uh-REK-tuh-me).

A hysterectomy can also be performed through an incision in the vagina (vaginal hysterectomy) or by a laparoscopic or robotic surgical approach — which uses long, thin instruments passed through small abdominal incisions.

An abdominal hysterectomy may be recommended over other types of hysterectomy if:

  • The patient has a large uterus.
  • The doctor wants to check other pelvic organs for signs of disease.
  • The surgeon feels it’s in best interest to have an abdominal hysterectomy.

Laparoscopic Hysterectomy

A laparoscopic hysterectomy is a minimally invasive surgical procedure to remove the uterus. A small incision is made in the navel through which a tiny camera is inserted. The surgeon watches the image from this camera on a TV monitor while performing the procedure. Two to three other tiny incisions are made in the lower abdomen. Through these, specialized instruments are inserted and used for the removal process.

Most women do not have their ovaries removed when they undergo a hysterectomy. If the ovaries stay inside, the woman does not need to take any hormones after surgery and she does not have hot flashes. Women can choose either to keep the cervix in place (that’s called a “supra-cervical hysterectomy”) or remove the entire uterus (“total laparoscopic hysterectomy”).

Keeping the cervix in place makes the operation a little faster and safer. Some people think that keeping the cervix in place is better for sexual enjoyment in the future. However, when the cervix is in place, there is a 5% chance that the woman will have monthly spotting at the time of her menstrual periods. Women whose cervices stay in place need to continue getting regular pap smears.

If the woman wants to be 100% certain that she will never menstruate again, she needs to have the entire uterus removed. If the patient has a history of pre-cancerous changes of the cervix or the uterine lining, she should have the entire uterus removed. If the operation is being done for endometriosis or pelvic pain, many doctors think the chances for pain reduction are better if the cervix is removed.

A laparoscopic hysterectomy requires only a few small incisions, compared to a traditional abdominal hysterectomy which is done through a 5-6 inch incision. As a result, there is less blood loss, less scarring, and less post-operative pain. A laparoscopic hysterectomy is usually done as an outpatient procedure whereas a traditional hysterectomy usually requires a 2-3 day hospital stay. The recovery period for this laparoscopic procedure is 1-2 weeks, compared with 4-6 weeks after a traditional hysterectomy.

The risks of blood loss and infection are lower with laparoscopic hysterectomy than with abdominal hysterectomy. In experienced hands, laparoscopic hysterectomy takes about the same length of time as abdominal hysterectomy and involves no greater risk.

Dilation and Curettage (D&C)

Dilation and curettage, often called a D&C, is a minor surgical procedure done to remove tissue from a woman’s uterus (womb). It is usually an outpatient surgery that can be done in a doctor’s office or surgery center. It is performed by a gynecologist or obstetrician.

The name refers to the dilation of the cervix, into which a thin instrument called a curette is inserted. The cervix is the narrow opening of the uterus that joins with the top of the vagina. It usually only dilates (opens) naturally during childbirth.

A D&C may be necessary if a woman has had a miscarriage, has leftover tissue from an abortion in her uterus, or has unexplained bleeding between menstrual periods.

A D&C may also be done along with a procedure called a hysteroscopy. In this procedure, a device is inserted to view the inside of the uterus for diagnostic purposes.

Gynecologist or obstetrician will usually begin a D&C by giving you medication to relax or partially sedate you. The procedure will usually cause cramping like menstrual cramps. Patients may be given pain medication to deal with these cramps.

Your doctor may begin to dilate your cervix by using something called a laminaria stick before surgery. This is a thin rod that is inserted into the cervix and left in place for several hours. The rod absorbs fluids from the cervix, causing it to open, or dilate, and provide access to your uterus. Your doctor may also give you medications to help soften and numb your cervix.

Much like a gynecological exam, a D&C is performed with your back on a table and your feet in stirrups. A speculum will be inserted into the vagina. Cervix will be held in place with a clamp.

Once cervix is sufficiently dilated – about one-half inch in diameter – your doctor will use a suction device or a scraping instrument, called a curette, to clean out tissue from the uterus.

In most cases, your doctor will a take sample of the tissue for laboratory analysis following the procedure.

Amniocentesis

Amniocentesis is a procedure in which amniotic fluid is removed from the uterus for testing or treatment. Amniotic fluid is the fluid that surrounds and protects a baby during pregnancy. This fluid contains fetal cells and various chemicals produced by the baby.

Amniocentesis can provide valuable information about the baby’s health. Amniocentesis can be done for various reasons:

  • Genetic testing. Genetic amniocentesis involves taking a sample of amniotic fluid and testing it for certain conditions, such as Down syndrome.
  • Fetal lung testing. Fetal lung maturity testing involves taking a sample of amniotic fluid and testing it to determine whether the baby’s lungs are mature enough for birth.
  • Diagnosis of fetal infection. Occasionally, amniocentesis is used to evaluate a baby for infection or other illness. The procedure also can be done to evaluate the severity of anemia in babies who have Rh sensitization — an uncommon condition in which a mother’s immune system produces antibodies against a specific protein on the surface of the baby’s blood cells.
  • Treatment. If you accumulate too much amniotic fluid during pregnancy (polyhydramnios), amniocentesis might be done to drain excess amniotic fluid from your uterus.

Amniocentesis done before week 20 of pregnancy, it might be helpful to have your bladder full during the procedure to support the uterus. Drink plenty of fluids before your appointment. After 20 weeks of pregnancy, your bladder should be empty during amniocentesis to minimize the chance of puncture.

Guided by ultrasound, your health care provider will insert a thin, hollow needle through your abdominal wall and into the uterus. A small amount of amniotic fluid will be withdrawn into a syringe, and the needle will be removed. The specific amount of amniotic fluid withdrawn depends on the number of weeks the pregnancy has progressed.

Endometrial Ablation

Endometrial ablation is a procedure that surgically destroys (ablates) the lining of your uterus (endometrium). The goal of endometrial ablation is to reduce menstrual flow. In some women, menstrual flow may stop completely.

No incisions are needed for endometrial ablation. Your doctor inserts slender tools through the passageway between your vagina and uterus (cervix).

The tools vary, depending on the method used to ablate the endometrium. They might include extreme cold, heated fluids, microwave energy or high-energy radiofrequencies.

Some types of endometrial ablation can be done in your doctor’s office. Others must be performed in an operating room. Factors such as the size and condition of your uterus will help determine which endometrial ablation method is most appropriate.

Endometrial ablation is a treatment for excessive menstrual blood loss. Doctor might recommend endometrial ablation for:

  • Unusually heavy periods, sometimes defined as soaking a pad or tampon every two hours or less/li>
  • Bleeding that lasts longer than eight days/li>
  • Anemia from excessive blood loss

To reduce menstrual bleeding, doctors generally start by prescribing medications or an intrauterine device (IUD). Endometrial ablation might be an option if these other treatments don’t help or if you’re not able to have other therapies.

Endometrial ablation generally isn’t recommended for postmenopausal women or women who have:

  • Certain abnormalities of the uterus
  • Cancer of the uterus, or an increased risk of uterine cancer
  • An active pelvic infection

Endometrial ablation procedures vary by the method used to remove your endometrium. Options include:

  • Electrosurgery. A slender scope is used to see inside the uterus. An instrument passed through the scope, such as a wire loop, is heated and used to carve furrows into the endometrium. Electrosurgery requires general anesthesia.
  • Cryoablation. Extreme cold is used to create two or three ice balls that freeze and destroy the endometrium. Real-time ultrasound allows the doctor to track the progress of the ice balls. Each freeze cycle takes up to six minutes, and the number of cycles needed depends on the size and shape of your uterus.
  • Free-flowing hot fluid. Heated saline fluid is circulated within the uterus for about 10 minutes. An advantage of this method is that it can be performed in women who have an irregular-shaped uterus from abnormal tissue growth — such as intracavity lesions or uterine fibroids — that distorts the uterus.
  • Heated balloon. A balloon device is inserted through your cervix and then inflated with heated fluid. Depending on the type of balloon device, the procedure can take from two to 10 minutes.
  • Microwave. A slender wand is inserted through the cervix. The wand emits microwaves, which heat the endometrial tissue. Treatment usually lasts three to five minutes.
  • Radiofrequency. A special instrument unfurls a flexible ablation device inside the uterus. The device transmits radiofrequency energy that vaporizes the endometrial tissue in one to two minutes. The device is then removed from the uterus.

Endometrial ablation usually reduces the amount of blood lost during menstruation. Most women will have lighter periods, and some will stop having periods entirely.

Salpingo-oophorectomy

Unilateral salpingo-oophorectomy is the surgical removal of a fallopian tube and an ovary. If both sets of fallopian tubes and ovaries are removed, the procedure is called a bilateral salpingo-oophorectomy.

This surgery is performed to treat ovarian or other gynecological cancers, or infections caused by pelvic inflammatory disease. Occasionally, removal of one or both ovaries may be done to treat endometriosis, a condition in which the lining of the uterus (the endometrium) grows outside of the uterus (usually on and around the pelvic organs). The procedure may also be performed if a woman has been diagnosed with an ectopic pregnancy in a fallopian tube and a salpingectomy (an incision into the fallopian tube to remove the pregnancy) cannot be done. If only one fallopian tube and ovary are removed, the woman may still be able to conceive and carry a pregnancy to term. If both are removed, however, the woman is rendered permanently infertile. This procedure is commonly combined with a hysterectomy (surgical removal of the uterus); the ovaries and fallopian tubes are removed in about one-third of hysterectomies.

In a salpingo-oophorectomy, a woman’s reproductive organs are accessed through an incision in the lower abdomen, or laparoscopically. Once the area is visualized, a diseased fallopian tube can be severed from the uterus and removed. The ovary can also be removed with the tube. The remaining structures are stitched, and the wound is closed.

In a salpingo-oophorectomy, a woman’s reproductive organs are accessed through an incision in the lower abdomen, or laparoscopically. Once the area is visualized, a diseased fallopian tube can be severed from the uterus and removed. The ovary can also be removed with the tube. The remaining structures are stitched, and the wound is closed.

If performed through a laparoscope, the surgeon can avoid a large abdominal incision and can shorten recovery. With this technique, the surgeon makes a small cut through the abdominal wall just below the navel. A tube containing a tiny lens and light source (a laparoscope) is then inserted through the incision. A camera can be attached that allows the surgeon to see the abdominal cavity on a video monitor. When the ovaries and fallopian tubes are detached, they are removed though a small incision at the top of the vagina. The organs can also be cut into smaller sections and removed. When the laparoscope is used, the patient can be given either regional or general anesthesia; if there are no complications, the patient can leave the hospital in a day or two.