25 Benign conditions of the genital tract

Christopher B-Lynch

VAGINAL MALFORMATION septum through one of the compartments. If such a defect is detected before , a A number of vaginal malformations have CO2 laser excision or other appropriate sur- been described. The may be inacces- gical treatment can remove the septum and sible because of an intact . It also can facilitate creation of a normal functioning vagi- be malformed by a transverse (horizontal) or na. It is usual for women who are preconcep- vertical (longitudinal) septum. In the presence tional to complain if they have this condition, of a transverse septum, menstrual blood may because they experience difficulty in inserting not pass freely and a hematocolpos may also a or when attempting to be present. Vaginal examination should eas- have normal vaginal intercourse. The treat- ily identify the obstruction, and hematocolpos ment results are usually excellent. can be detected either by the presence of a tense fullness behind the septum, or with the aid of an ultrasound examination which will further delineate its extent and whether the is itself dilated with further menstrual The vagina develops from the cloacae and is fluid collection. A cruciate incision under gen- usually covered with squamous epithelium. eral anesthesia is generally all that is required Because of its proximity to the , which to correct this abnormality. A partial or sub- develops from the same epithelial anlagae, septum can be high or low in the vagina. The similar malformations to those of the anal lower it is the better is the prognosis for preg- canal may occur. Vaginal atresia may be asso- nancy, and complete excision can be achieved. ciated with an absence of rudimentary devel-

Excision can also be achieved by using a CO2 opment of the uterus known as the Rokitan- laser. This results in very little surgical trauma sky syndrome, most commonly presenting at and minimal tissue is created. The prog- with or nosis for pregnancy is good for a low septum in the presence of normal secondary sexual and much reduced for a high septum. characteristics. If the use of regular vaginal A vertical (longitudinal) septum may be dilators fails, then a variety of surgical tech- present in variable lengths up to a complete niques performed in collaboration with a plas- separation of the vagina creating two cavities. tic surgeon could be beneficial. This can occur as either a high or low septum If the uterus is underdeveloped and has or a complete partition of the vagina. There failed to connect with the vagina then surro- have been instances where normal vaginal gacy would seriously have to be considered as delivery has occurred alongside a longitudinal a childbearing option.

355 PRECONCEPTIONAL MEDICINE

UTERINE MALFORMATION surgery can be performed, the benefit of suc- cessful and advanced pregnancy is by no means A variety of uterine malformations have been guaranteed. Some forms of described varying from a may have a redundant horn or a dominant (Figure 1) to complete division or duplication horn. If pregnancy occurs in the redundant of the uterus, commonly described as a double horn, the chance of or rup- uterus with two horns separated in its low ture of the uterus is higher. In some cases a end, along with two tubes and two ovaries1. redundant horn can obstruct the passage of These patients are usually but the fetal head into the canal from the may present with fertility problems, recurrent pregnancy that is in the dominant horn. Care- , scanty and painful ful evaluation is important to understand the or heavy periods. They are susceptible to pre- nature and extent of the problem well before term labor and abnormal presentation of the pregnancy occurs. fetus. An ultrasound scan can identify the con- When a septum is discovered within the dition well before pregnancy. , it is appropriate to remove it A unicornuate uterus has a high miscarriage using a hysteroscopic approach, which is com- and premature labor rate which may lead to monly followed by an immediate insertion anything from extreme prematurity to late of an intrauterine contraceptive device of the prematurity and immature development of Mirena type for 6 weeks to minimize the fetus. It is commonly acknowledged that formation. if a unicornuate uterus has carried a pregnancy The numerous varieties of malformation to term the prognosis is good for subsequent make it imperative that during the course of . investigating patients for all clini- The well known Strassman’s operation, cians undertake proper physical examination which involves incision at the uterine fundus to exclude abnormalities of the genital tract1. from one horn to the other transversely and then re-suturing anteriorly and posteriorly to create a larger cavity, theoretically may enable GENITAL the patient to carry a pregnancy to a more advanced gestation. Though such corrective Genital warts commonly present in young women, often before they become pregnant. The method of transmission is still unclear, although the causative viral agent is well known. The vast majority of cases are man- aged in the specialist genitourinary medical clinic; although in many countries manage- ment is in the hands of generalists or obste- tricians/gynecologists. Some centers provide medication for self application at home with the inherent pitfalls in managing such a con- dition effectively (especially when the warts are extensive) by this protocol. Guidelines are available from von Krogh et al. and the Health Figure 1 Patient aged 35. Unicornuate uterus Protection Agency2,3. with congenital absence of left tube and . In the UK about 71,000 new cases of genital Copyright Mr C. B-Lynch 2009 warts are reported annually by genitourinary

356 Benign conditions of the genital tract medicine clinics. A common association with anal region. Appropriate blood screening tests is present. Women with could differentiate these various diagnoses. these conditions experience local of Treatment is not always necessary, as a pro- the and vagina as well as marked . portion of these warty lesions resolve sponta- Human papillomavirus (HPV) is the cause of neously5. However, many clinicians will treat all infection and has the associated risk of cervical cases because it is not possible to distinguish at a later date in some individuals, as those lesions which regress ­spontaneously. HPV types 16 and 18 are found in most cases of . As such, the infection is a particularly relevant condition for discussion Treatment in terms of preconceptional medicine. Follow- ing initial diagnosis, the behavior in pregnancy For mothers who are contemplating and plan- is unpredictable. Often the pregnant state is ning a pregnancy it is prudent to treat vis- associated with marked growth of the warts ible lesions before becoming pregnant. No which, if not treated in a timely basis, can treatment modality can be guaranteed to be become problematic in terms of general com- 100% effective and relapses can occur. Treat- fort and, in some instances, locomotion. When ments such as podophyllin and imiquimod can be applied. Long-term toxicity (espe- neglected, obstruction of vaginal delivery is a cially if lesions are large) may mean using an possibility. It is probable that the immunosup- alternative such as podophyllotoxin. This is a pressive effect of pregnancy may opportunisti- cytotoxic agent with the active component of cally charge these viral eruptions to prolifer- podophyllin. It is applied as a cream base and ate. Currently young adolescent women are is effective in young women. Other treatments offered immunization, but evidence of the such as imiquimod, cryotherapy and trichloro- long-term effectiveness of this program is acetic acid are recommended either in isola- awaited. Genital warts can be found anywhere tion or in combination6. around the tract of the female genitalia includ- In pregnancy warts tend to grow quite rap- 4 ing the introitus, vulva, vagina and . idly. Small warts can be treated conservatively; larger warts can be excised even in pregnancy. Cervical warts should be excised using the Diagnosis laser, and when warts are large and invading the vagina, serious consideration should be Most cases of genital warts are diagnosed by given to delivery of the baby by cesarean sec- visual appearance with the individual lesions tion. Transmission from mother to baby can displaying characteristic warty heads. These occur if lesions are present in the vagina. Pedi- are contagious and can be passed onto the atric manifestations of genital wards include male and vice versa. Collaboration with a der- laryngeal polyps of the and toddler. matologist is often helpful, because the dif- Treatment with podophyllotoxin should ferential diagnosis includes uninfectious skin be avoided in pregnancy because of concerns lesions including malignancies. It is essential regarding potential toxins. Urethral warts can not to confuse sexually transmitted diseases be cauterized. In pregnancy, surgical remov- with other genital warts such as molluscum al of localized warts is recommended, but contagiosum which are flatter eruptions of recurrence may occur after apparent surgical the vulva and contain central cheesy material. ­clearance. Another consideration should be condyloma Because the chances of greater proliferation lata of secondary which are softer more of viral changes could be high in patients fleshy lesions especially confined to the peri- who are HIV positive and pregnant, these

357 PRECONCEPTIONAL MEDICINE individuals should be managed jointly between BENIGN TUMORS OF THE the sexually transmitted disease unit and the BARTHOLIN’S HIV consultant. It is also good practice to screen for other sexually transmitted diseases The Bartholin’s provide appropriate in patients who request HIV screening, regard- secretions following sexual stimulation to less of whether they are pregnant at the time prevent or minimize friction during sexual of the request. ­intercourse. Ideally, patients with genital warts should From time to time, obstructions of the duc- have annual cervical smears before becoming tal aspect of the gland cause swelling, pain pregnant. Genital warts are rarely associated and/or edema of the gland or infection by bac- with oncogenic HPV . Transmission terial tracking of the which causes inflam- of genital warts can be controlled by the use of mation of the gland leading to , intense barrier methods of contraception such as the pain and fever. This is sometimes , which may prove valuable preventive described as the greater vestibular gland in the measures against other HPVs3. lower third of the majora. Inflammatory changes can occur at any time before or during pregnancy, causing pain and discomfort along Summary with fever or abscess formation. Active and urgent management is indicated. Key points regarding genital warts include: Independent of the Bartholin’s gland, super- ficial vulval cysts may or may not become sec- • The diagnosis of genital warts is usually a ondarily infected. Most often, they are asymp- clinical one tomatic and require no treatment even in • HPV 6 and 11, which are not associated pregnancy other than to occasionally discharge with an increased risk of malignancy, are a cheesy-like substance. In such instances, associated with 90% of wart infections excision in conjunction with antibiotics of appropriate culture and sensitivity may be • Most patients can be treated at home with considered. topical agents such as podophyllotoxin or Changes in vulva pigmentation need advice imiquimod regarding further management as 10% of pig- • All treatments, including ablative treat- mented lesions can become malignant mela- ment, have a relapse rate of around 30% nomas. In pregnancy, pigmented lesions are • Warts have a natural history and may particularly susceptible to further changes, regress spontaneously and the pigmentation per se probably reflects the immunosuppressant effect of pregnancy. • No treatment is always an option • Screening for other sexually transmitted infections (STIs) should be routine for any VULVAL ­INTRAEPITHELIAL patient presenting with genital warts NEOPLASIA • Currently, vaccines are available to inocu- Vulval intraepithelial neoplasia (VIN) is com- late against HPV infections of malignant monly a feature of squamous origin (Bowen’s potential. Evidence of their long-term disease or Bowenoid papulosis), in which grad- effectiveness is eagerly awaited. ing the severity of changes depends on clinical • All wart infections have the capacity appearance as well as not unlike the to grow in pregnancy when the immune grading of cervical intraepithelial neoplasia response may be suppressed. (CIN). The lesion might have a rough surface

358 Benign conditions of the genital tract and be flattened like vulval wart infection others. The larger is the surface area of abnor- but can also appear with indistinct borders. mality, the greater is the chance of scar tissue Paget’s disease can present with similar formation after the loop excision procedure. appearances to VIN. These are also uncom- Sometimes the scarring is sufficient to inter- mon and have demarcated borders, are very fere with conception and in other instances commonly multifocal, are eczematoid in char- in the process of parturition. It is common to acter and are associated with 25% of adeno- warn patients who have had loop excision sur- carcinoma within the , perianally or at gery of these risks and for health care person- distant sites. The recommended treatment is nel to assess the cervix when patients are in wide excision of the focal lesion in consulta- labor and possibly explain any slow progress. tion with a colorectal­ surgeon preoperatively. A cone biopsy is sometimes necessary for high grade colposcopic lesions. This opera- tion, which removes the abnormal area along CERVICAL ­INTRAEPITHELIAL with normal tissue in a cone shaped specimen NEOPLASIA is usually performed under regional or gen- eral anesthesia, either as a cone loop excision Lesions of this type are premalignant condi- or knife cone biopsy. Unfortunately, the cer- tions, and many women have had abnormal vix may be shortened or scarred significantly smears prior to pregnancy. The various clas- afterwards, and, in a worst case scenario, may sifications of such abnormalities include terms lead to difficulty in passing menstrual blood such as mild, moderate or severe dyskaryosis. and/or retention of menstrual blood in the These gradings mainly indicate changes in the uterine cavity (hematometra) along with con- cellular pattern from mild to severe in progres- siderable pain. This latter condition is relieved sion which signify high or low risk. when the cervix is dilated to empty the uterus. Liquid based cytology was recently intro- It is important only to dilate the cervix to a duced to achieve more robust detection of the reasonable diameter so as not to cause cervical presence of abnormal cells and their character. incompetence or interfere with the integrity of This process also enables the non-visible type subsequent pregnancy. Follow-up Papanicolau of wart virus that may be present on the cer- smear may become necessary even in the early vix to be identified and classified as to which part of pregnancy. Most other investigations, group it belongs, including HPV 16 and 18 including follow-up smears after successful both of which have malignant potential. treatment, can be performed 3 months after Following an abnormal smear report, the the postnatal period. patient should have a colposcopic examina- tion. The biopsy taken at the time of this pro- cedure will diagnose and classify the abnor- MENORRHAGIA AND mality into a high or low risk category (CIN high or low grade)7. The quantity and significance of heavy peri- The impact of this procedure in pregnancy ods is usually difficult to assess8,9. The classi- is now well recognized. Biopsy is commonly cal categorization of heavy periods describes performed as a loop excision of the transfor- approximately 40 ml with 70% loss in the first mation zone (the boundary is where the glan- 48 hours in the healthy European population. dular cells border the squamous cells). This As this is a subjective definition, the clinical border may harbor 95% of the abnormal cells impact of excessive is assessed based of precancer or cancer origin. Some on the clinical features described by patient have a larger surface area of abnormality than including tiredness, listlessness, pallor as well

359 PRECONCEPTIONAL MEDICINE as when assessed by hemoglobin val- and then to consider the consequence of these ues10. Menorrhagia commonly leads to iron examinations on the patient’s fertility poten- deficiency anemia. The impact of which is even tial. In this regard, preconceptional diagnosis more significant in the less developed world not only determines the feasibility of preg- where a patient might attempt to accomplish nancy and its uneventful progress but also the activities of daily living with hemoglobin diagnoses conditions the treatment of which levels at half the value of those of women in facilitates pregnancy11. the western world. Because is a classic cause of Menorrhagia is one of the main reasons spasmodic dysmenorrhea and dyspareunia, a for seeking medical advice, and was a com- diagnostic laparoscopy could reveal this early mon indication for as late as enough to enable appropriate treatment. Such the 1980s when about 40% of women having investigations may also provide the opportu- a hysterectomy listed this reason for seeking nity to assess tubal and ovarian function char- surgical therapy. In the UK, 1 in 5 women have acteristics (Figure 2). their uterus removed by the age of 55, albeit with a significant proportion of the pathology reports showing a normal uterus, with dys- UTERINE FIBROIDS functional uterine bleeding having been the principle cause of heavy periods11. Fibroids are benign tumors the size and loca- The introduction of ablative therapy has tion of which are variable. As such they can reduced the incidence of hysterectomy dra- be submucosal, intramural, subserosal, intra- matically since the 1990s12. Currently, surgical cervical or pedunculated and in the broad liga- procedures such as hysterectomy are balanced ment. Fibroids are well circumscribed, with a whorl type of soft tissue, appearing in approxi- against the potential associated mortality and mately 20% of women of reproductive age, morbidity risks of these operations versus the many of whom are asymptomatic. far lesser morbidity of the ablative regimens. They are extremely common in the Afro-­ Most women with menorrhagia also com- Caribbean population where most women plain of dysmenorrhea, particularly women in tolerate their symptoms remarkably well even the fertile age group and where other causes of heavy periods have not been excluded such as fibroid uterus, endometriosis, pelvic inflam- matory disease (PID) and malignant or prema- lignant conditions of the uterus. In a signifi- cant proportion of instances of dysmenorrhea, the character may be congestive or spasmodic, although usually with congestive dysmenor- rhea pain appears before bleeding starts and promptly decreases in severity during the flow. In contrast, the spasmodic variety worsens with menstrual flow past the first day. It is important to understand this difference, because women who have spasmodic dysmen- orrhea may well have endometriosis or adeno- myosis that needs early diagnosis and therapy. Figure 2 Patient aged 32. Bilateral ovarian endo- The presence of dysmenorrhea should alert the metriosis in pouch of Douglas (the kissing clinician to perform appropriate investigations syndrome). Copyright Mr C. B-Lynch 2009

360 Benign conditions of the genital tract though they are often anemic. A significant the patient becomes reluctant to persevere proportion of patients with fibroid tumors with medical treatment. are reluctant to have any form of surgical The luteinizing hormone releasing hormone ­intervention. (LHRH) analogue (goserelin) is used to shrink The introduction of fibroids and control bleeding by suppressing (embolization) has presented a new option for ovarian function, generally as pretreatment the management of fibroids. In 2004 the Nation- for myomectomy or prehysterectomy for very al Institute of Clinical Excellence (NICE) pro- large fibroids. Decapeptyl 3 mg injection on a vided guidance for clinicians to consider uter- monthly basis for 6 months or goserelin 3.6 mg ine embolization for the treatment of monthly by injection for the same duration are fibroids, although it is important to note that both acceptable. Patients administered either currently no concrete data exist pertaining to of these medications should be warned about the effectiveness or outcome of embolization the side-effect of premature chemical meno- procedures for treatment of fibroid tumors, pause and might need some adback treat- including the preservation of fertility poten- ment such as tibolone or low-dose tial, or the reduction of potential fecundity in to reduce the disturbing effect of patients who wish to conceive. The NICE docu- ­withdrawal. ment comments on indications, means of per- formance of the procedure, ethics, safety and reduction in mean fibroid volume and blood ENDOMETRIOSIS loss13. Counseling and consenting of such women is essential for those who consider The etiology of endometriosis is unknown. this alternative procedure in the management Common clinical features suggest ectopic of fibroid uterus1. Uterine artery embolization deposits of endometrial tissue outside the should not be recommended without careful uterine cavity itself or ectopic location within consideration in the treatment of symptomatic the per se, when the condition is uterine fibroids, endometrial polyp or submu- termed adenomyosis. Apart from heavy men- cosal fibroid1. struation, endometriosis is characteristically Women who have had the uterine cavity associated with severe dysmenorrhea of the open during a prior myomectomy should be spasmodic type. The location of endometriosis offered cesarean section when they become is variable and can involve organs such as the pregnant to minimize or avoid the risk of uter- bladder and rectum that lie within the pouch ine rupture. of Douglas11 (Figure 2) or involving one or both ovaries ­either superficially or within its depth. Conjunctive medical treatment Foci of endometriosis can also be found in distant organs such as the appendix, bowel, Medical treatment for fibroids and menorrha- diaphragm or pulmonary area. Regarding fer- gia can be achieved by the use of mefenamic tility potential, it is essential to ascertain that acid, tranexamic acid, non-steroidal anti- the tubes are not involved. If the ovaries are inflammatory drugs (NSAIDs) or antifibrino- involved, appropriate treatment should be lytic agents. All are useful medical treatment administered to facilitate pregnancy where for menorrhagia, but are not effective in every indicated (Figures 3 and 4). A significant num- patient. Commonly in fibroid menorrhagia, ber of patients with endometriosis become one or another of these agents may control pregnant spontaneously and their symptoms bleeding but not the pain. If the pain persists, characteristically resolve whilst they are no

361 PRECONCEPTIONAL MEDICINE longer menstruating. This is not to say that and inefficient bowel emptying (Figures 5–8). they are cured, but their symptoms abate Endometriosis is a significant problem for markedly, although there is no evidence to women, especially those in the fertile age show that pregnancy cures endometriosis. group where its presence not only causes Patients with endometriosis commonly classic menorrhagia and dysmenorrhea but complain of deep dyspareunia because of the also sexual problems. In extreme cases, pel- position of the uterus, as endometriosis with- vic endometriosis can require bowel resection in the pouch of Douglas commonly causes with bypass or diversion surgery, or, in cases of uterine retroversion and fixation. If endome- ureteric involvement, bypass or diverted uri- triosis involves the rectum and lower bowel, nary tract surgery. patients can complain of painful defecation

Figure 3 Patient aged 32. Surgical marsupializa- Figure 5 Patient aged 30. Severe uterine retro- tion, irrigation and drainage, followed by goserelin version and retroflexion. Copyright Mr C. B-Lynch medical treatment. Copyright Mr C. B-Lynch 2009 2009

Figure 4 Patient aged 32. Surgical treatment Figure 6 Patient aged 30. Vaginal manipulation result. Uneventful pregnancy 6 months later with of uterus to test for successful laparoscopic uterine normal delivery. Copyright Mr C. B-Lynch 2009 ventrosuspension. Copyright Mr C. B-Lynch 2009

362 Benign conditions of the genital tract

white (resolving) characteristics. Patients’ symptoms often do not correlate with the laparo­scopic severity of endometriosis. Treat- ment must be individualized taking the entire clinical picture into account. Quality of life and fertility potential are crucial in the man- agement of this condition. When the bowel is involved, it is mandatory that a colorectal surgeon forms part of a multidisciplinary team management (Figures 3 and 4). Clinical features should be comprehensive. Deep infiltrating nodular lesions are best pal- pated during menstruation. Transvaginal scan Figure 7 Patient aged 30. Right round may have a role in the diagnosis of the disease lift and fixation. Copyright Mr C. B-Lynch 2009 involving the bladder or rectum but is of lim- ited value. Magnetic resonance imaging (MRI) can be superior to ultrasound scan but not of greater benefit compared to laparoscopy. The chemical marker CA125 may be elevated in endometriosis, but its elevation is not always diagnostic of the condition. Women who want to avoid hormonal thera- py to treat their pain should consider NSAIDs. Assisted should be considered to improve fertility chances in minimal to mild endometriosis. In vitro fertilization (IVF) is an appropriate treatment for endometriosis espe- cially when tubal function is compromised. Laparoscopic ovarian cystectomy is recom- mended for endometriotic cysts greater than 4 cm in diameter. Surgical treatment for endo- Figure 8 Patient aged 30. Left round ligament lift metriomas is often useful before IVF, although and fixation for relief of deep dyspareunia. Unevent- women should be counseled regarding the risk ful pregnancy and normal delivery following laparo- of reduced ovarian function after surgery. scopic ventrosuspension. Copyright Mr C. B-Lynch Treatment with gonadotropin releasing 2009 hormone (GnRH) 3–6 months before IVF in women with endometriosis often increases the rate of clinical pregnancy. Finally, it is worth noting that patient self help groups can pro- It is important to manage the clinical fea- vide invaluable counseling support and advice. tures of endometriosis and properly inves- tigate these patients, offering medical treat- ment first. Patients with endometriosis should undergo laparoscopy, at which time lesions can be classified as having pink (early inflam­ Pelvic pain in women may or may not be matory changes), chocolate (established) or associated with significant pathology. Many

363 PRECONCEPTIONAL MEDICINE women who experience pelvic pain outside the of this condition. The choice of antimicrobial normal have conditions that or antibacterial therapy will be dependent on may affect their fertility such as PID, adhe- the clinical presentation and the need for sin- sions or pelvic cysts. PID in premenopausal gular or broad spectrum cover. It is not accept- women and particularly pre-pregnancy wom- able to delay medical treatment when PID is en may result from bacterial infection or STI. suspected or diagnosed. The end point is usually described as terminal All mothers should have counseling about hydrosalpinges with flimsy pelvic adhesions. the presence of such in the vagina as The collection of inflammatory material at the soon as the diagnosis is made in pregnancy. resolution stage of and Chlamydia PID can cause a significant amount of pain, infections shows typical tubal distension, dis- deep dyspareunia and distortion of the pelvic tortion, irregularity and thinning of the tubal . wall, which may then progress to a chronic inflammatory form. Because hydrosalpinges can contain immune complexes resulting from BENIGN PELVIC CYSTS the resolution process which can affect the IVF success rate, may improve The most common cyst in young women of the chance for success in patients who have fertile age is the dermoid cyst. Dermoid cysts had tubal disease prior to IVF treatment. represent congenital cysts arising from the Infected products of conception from a migration of the ovary from the mesenchy- miscarriage may cause proximal damage or mal ridge down to the pelvis assisted by the occlusion of the tube commonly described round ligament to its definitive position on the as cornual blockage. Such patients have very ovarian fossa. These ovaries may contain cells little or no chance of conceiving even after capable of a variety of tissue differentiation of tubal reconstructive surgery, and IVF remains no ovarian function. The cysts can be found the key management strategy. Diagnostic pro- incidentally on ultrasound scan or computed cedures ( and laparoscopy) are tomography (CT) evaluation. Whenever large essential to exclude genital tract abnormality cysts are discovered these should be removed and to ascertain the exact site of chronic PID. by laparoscopy or open surgery as appropriate, In the vagina itself, about 20% of women as torsion is always possible and can result in may have bacterial colonization, including destruction of viable ovarian tissue and con- group B streptococci and sometimes coliform siderable morbidity. bacteria, which ultimately may affect not only Dermoid tumors have a very low chance, the prospect of IVF success but also pregnancy about 10%, of malignant potential. Careful outcomes. Group B streptococci may cause management of this condition should be dis- premature rupture of the membranes and cussed with the patient who wants to become can affect the baby leading to serious neona- pregnant. tal morbidity. When group B streptococci are Whereas it is acceptable to remove the cyst found colonizing the vagina in pregnancy the and conserve the ovary, there is never an abso- protocol of management should be multidisci- lute indication to remove the ovary because it plinary including a bacteriologist, pediatrician, contains a dermoid cyst. Clinical consideration obstetrician and neonatologist. It is because must be given to the fertility status or precon- of the significant consequences of PID that all ception state of the patient and general clinical clinically diagnosed patients should be treated condition before is carried out immediately to protect against any progression for a dermoid cyst (Figures 9–12).

364 Benign conditions of the genital tract

Figure 9 Patient aged 19. Presented with 35 cm Figure 11 Patient aged 19. Dermoid cystectomy left dermoid cyst. Laparoscopically deflated and excised and confirmed histologically. Copyright Mr aspirated. Copyright Mr C. B-Lynch 2009 C. B-Lynch 2009

Figure 10 Patient aged 19. Cyst exteriorized and Figure 12 Patient aged 19. Replacement of left extracorporeal left ovarian cystectomy performed. ovary into pelvis. Copyright Mr C. B-Lynch 2009 Copyright Mr C. B-Lynch 2009

BENIGN OVARIAN CYSTS Although there is a 10% chance of these cysts (UNILOCULAR CYSTS) becoming malignant, the vast majority if prop- erly evaluated require only laparoscopic sur- These conditions exist as benign serous cyst- gery. It is well recognized that cysts can grow to adenomas or benign mucinous cystadenomas an enormous size, often in the pre-­pregnancy and are normally diagnosed after cystectomy patient, and their excision necessitates skilful when no other clinical indication of abnor- laparoscopy or laparotomy. mality is present within the cyst. Preoperative If all the markers are strongly suggestive of assessment may include the CA125 marker a benign condition, then removing the cyst test, which if elevated must be investigated by while conserving ovarian tissue is appropriate further high definition scan and other markers. and beneficial to the pre-pregnancy patient. To

365 PRECONCEPTIONAL MEDICINE do nothing is not an option, as it is well recog­ nized that cysts can undergo torsion which would require prompt ovarian cystectomy.

SALPINGIAN CYSTS

These cysts are usually of moderate size and are commonly diagnosed as an incidental find- ing at routine laparoscopy. If they are tiny, they can be left alone. On the other hand, if they are of a size which might interfere with tub- al function by way of torsion, they should be removed laparoscopically, first by deflating the Figure 13 Patient aged 26. Drilling diathermy cyst and then resecting the stalk. Occasionally treatment. Copyright Mr C. B-Lynch 2009 postlaparotomy adhesions may present with loculated cystic formations within adhesion pathophysiological basis of the condition has strands or bands which appear as ovarian cysts improved enormously and a variety of treat- with the potential to have false imaging and ment options have been suggested with favor- mislead the clinician. Such cysts should be able results15,16. assessed carefully by CT or MRI scanning and This condition, common among women of interpreted by an interventional radiologist. It reproductive age, has generated much debate is safer to be conservative rather than to pro- regarding its definition and diagnosis. Apart ceed to further laparotomy. from chronic anovulation and oligomenor- It is most essential to evaluate clinical cystic rhea, it causes fertility problems for a signifi- changes thoroughly before surgical interven- cant number of women with the diagnosis17. tion, as a proportion of cysts do not originate Normally, two categories of patients having from a gynecological organ. Occasionally retro­ this condition come to attention. On the one peritoneal cysts masquerade as pelvic cysts. hand, there is the patient who presents with Clinicians must always seek the advice of sur- oligomenorrhea and is worried about the con- gical colleagues when the diagnosis is in doubt dition; on the other, there are patients who and in the best interest of the patient. experience anovulation and are worried about fertility prospects. In the former category, reassurance is prob- POLYCYSTIC OVARIAN SYNDROME ably all that is necessary. If medical treatment is required, metformin potentiates Polycystic ovarian syndrome (PCOS) pres- activity and may correct the condition and ents problems for the patient as well as her facilitate a return of menstruation. Unfortu- gynecologist. The historical background of nately, a significant number of these women this condition goes back to 1845 when Chere- do not respond to metformin in terms of res- au first described the sclerotic changes of toration of ovulation. This medication, backed the ovaries. Almost a century later, in 1935, by clomiphene, may improve the prognosis Stein and Leventhal14 described the classical for pregnancy, but not in all circumstances. features of PCOS and proposed wedge resec- Overcoming the insulin resistance by metfor- tion of the ovary as treatment (Figure 13). In min is not the only pathological process war- subsequent years, our understanding of the ranting treatment to achieve fertility. A body

366 Benign conditions of the genital tract of evidence shows that insulin resistance is patients with successful ovulation confirmed the principle underlying defect and treatment by day 21 progesterone and 17 pregnancies target. Such therapy may not only resolve the out of 24 women wishing to get pregnant immediate clinical problem but also has the (71%). Eleven patients were treated for irregu- potential to reduce the risk of vascular dis- lar cycles, hirsutism, premenstrual syndrome ease in later life17. Another group of patents and/or pelvic pain. There was one miscarriage have hyperandrogenemia. These patients may at 8 weeks, but nine pregnancies resulted in also have hirsutism as a problem in addition the birth of normal live babies. to their fertility problems. Obesity is a recog- The conclusion of this small study was that nized ­association. clinicians should consider this effective laparo- Commonly three approaches are used in the scopic surgical technique with ovarian drilling management of PCOS in young women. The when medical treatment has failed to produce first is to treat the symptoms with antiandro- fertility. The paper of Sinha and B-Lynch16 gens for conditions such as hirsutism, then to also showed a reduction in miscarriage rates. use contraception for menstrual irregularities Women with PCOS achieving pregnancy might and finally to institute ovulation induction for suffer from a short luteal phase for which pro- the preconceptional patient who is actively seeking pregnancy. Induction of ovulation can gesterone therapy might be useful. be prompted medically or using ovarian dia- It is important to understand that wom- thermy with the laser or wedge resection. en with PCOS do not all fail to get pregnant Sinha and B-Lynch demonstrated successful spontaneously. The condition can exist in a ovulatory responses following the use of the variety of forms, such as in one ovary but not YAG laser in the form of marsupialization of the other, or in both ovaries. It is because of the ovary16. This technique was further sup- the bizarre nature of this condition that active ported by Aziz and B-Lynch with an equally management should be encouraged in women good outcome18 (Figure 14). These techniques who seek to become pregnant and fail with found markedly reduced serum LH concentra- medical treatment as a first line. tions and normal menstrual cycles in 32 (91%)

ACKNOWLEDGMENT

The author wishes to acknowledge medical artist Mr Phillip Wilson for his assistance in producing the figures for this chapter.

References

1. Drife J, Magowan B. Clinical and , 1st edn. Edinburgh: Saunders, 2004 2. von Krogh G, Lacey CJN, Gross G, et al. Euro- pean guideline for the management of ano- Figure 14 Patient aged 26. Stromal depth genital warts. Int J STD AIDS 2001;12(Suppl exposure. Histology confirmed polycystic ovary. 3):40–7 Uneventful pregnancy and normal delivery 12 3. Health Protection Agency. Focus on Prevention. months later. Copyright Mr C. B-Lynch 2009 HIV and Other Sexually Transmitted ­Infections in

367 PRECONCEPTIONAL MEDICINE

the UK in 2003. An update: November 2004. 11. Bowen Simpkins P. Modern management London: HPA, 2004 of menorrhagia. Trends Urol Gynaecol Sexual 4. Sonnex C, Scholefield JH, Kocjan G, et al. Health 2006;May/June:12–19 Anal human papillomavirus infection in het- 12. NICE. NICE clinical guideline 44. January erosexuals with genital warts: prevalence 2007. www.nice.org.uk/nicemedia/pdf/ and relation with sexual behaviour. BMJ cg44niceguideline.pdf 1991;303:1243 13. NICE. Uterine artery embolisation for the treat- 5. Department of Health. The National Strategy ment of fibroids. NICE Issue date October for Sexual Health and HIV. London: Depart- 2004. www.nice.org.uk/nicemedia/pdf/ip/ ment of Health, 2001 IPG094guidance.pdf 6. Maw R. Critical appraisal of commonly used 14. Stein IF, Leventhal ML. Amenorrhoea associ- treatment of genital warts. Int J STD AIDS ated with bilateral polycystic ovaries. Am J 2004;15:357–64 Obstet Gynecol 1935;29:181–91 7. Cartier R, Cartier I. Practical , 3rd 15. RCOG. Endometriosis, Investigation and Man- edn. Paris: Laboratoire Cartier, 1993 agement. Green-top Guideline No.24 October 8. Warner PE,Critchley HD, Lumsden MA, 2006. www.rcog.org.uk/womens-health/ Campbell Brown M, Douglas A, Murray guidelines G. Menorrhagia II: Is the 80 ml blood loss 16. Sinha P, B-Lynch C. Clinical, biochemical criterion useful in management of com- and biophysical outcome of polycystic ovar- plaint of menorrhagia? Am J Obstet Gynecol ian syndrome in patients treated by endo- 2004;190;1224–9 scopic YAG laser surgery. Gynaecol Endosc 9. Reid PC, Coker A, Coltart R. Assessment 1993;3:143–7 of menstrual blood loss using a pictorial 17. Fleming R. New approaches to polycystic chart: a validation study. Br J Obstet Gynaecol ovarian syndrome (Editorial). Trends Urol 2000;107:320–2 Gynaecol Sexual Health 2000;May/June 10. Oehler MK, Rees M. Excessive menstrual 18. Aziz AI, B-Lynch C. Ovarian marsupialisa- bleeding. In: Rees M, Hope S, Ravnikar V, tion for polycystic ovarian disease: reality or eds. The Abnormal Menstrual Cycle. London, fiction?J Obstet Gynecol 1999;19:298–9 New York: Taylor and Francis, 2005:62–3

368