Uterine cancer

Uterine cancers are the most common female genital cancer in the developed world and the fourth most common malignancy in women. In South Africa and most developing countries it is the second most common genital tract malignancy after cervical carcinoma. While the incidence of uterine cancers is marginally higher in developed countries (5.9 vs 4 per 100,000), the disease-specific mortality rate is higher in developing countries. Uterine cancers include tumours that develop in the endometrium (carcinomas), the endometrial support cells (endometrial stromal sarcomas), and the myometrium (sarcomas). Endometrial carcinomas represent over 90% of uterine cancers, the incidence of which is increasing and is most likely driven by longer life expectancy, obesity, and a sedentary lifestyle. Most endometrial carcinomas present in postmenopausal women; however, in women with significant risk factors (such as unopposed endogenous oestrogen production as occurs in women with polycystic ovarian syndrome) or a genetic predisposition such as hereditary non-polyposis colorectal cancer (HNPCC)/Lynch 2 syndrome, tumours may present before the age of 40 years. Sarcomas constitute less than 10% of uterine cancers, the majority of which are leiomyosarcomas. Only 2% of uterine sarcomas originate in the endometrial stromal tissue. Most sarcomas present between the age of 40 and 60 years. For the purpose of this chapter, endometrial carcinomas and sarcomas will be discussed separately.

Premalignant and malignant disease of the cervix

Cervical cancer is a disease of poor and unscreened populations. Globally, it is the fourth most common cancer in women with over half a million new cases and over a quarter of a million deaths per year. About 85% of cases occur in less developed regions. Systematic high coverage and quality-assured population screening for precursors to cervical cancer is highly effective. Human papillomavirus (HPV) DNA testing will probably replace or complement cytology as the primary screening tool in many developed countries for women over 30 years of age. Because of the absolute relationship between oncogenic HPV and cervical cancer, its negative predictive value is very high. Management of cervical cancer is to determine the stage of the disease and to treat both the primary lesion and other extracervical disease. Cervical cancers spread by direct spread into the cervical stroma, parametrium, and beyond, and by lymphatic metastasis into parametrial, pelvic sidewall, and para-aortic nodes. Women should be fully staged using the International Federation of Gynecology and Obstetrics system and discussed in expert multidisciplinary forums with specialist surgeons, oncologists, pathologists, radiologists, and specialist nurses. Both surgery and radiotherapy are effective in early-stage disease, whereas locally advanced disease relies on treatment by radiation or chemoradiation. Surgery does provide the advantage of conservation of ovarian function. Women who have been treated for cervical precancer are much more likely to develop cervical cancer. Post-treatment HPV testing is the most sensitive test, has the best negative predictive values, and is the best test of cure.

Cancer screening and prevention in gynaecology

In 1968, the World Health Organization published guidelines on the principles and practice of screening for disease, which are often referred to as the ‘Wilson and Jungner criteria’. These principles are still applicable today. With the onset of genetic screening, new controversies around screening emerged and in 2008, Andermann et al. synthesized and modified the Wilson criteria. Screening is a systematic attempt to select those who are at high risk of a specific disease from among apparently healthy individuals. The ultimate aim of screening is prevention of disease or to detect disease at an early, curable stage. There are many controversies about screening for cancer, such as the use of prostatic-specific antigen screening for prostate cancer, mammography screening for breast cancer, and debates around current screening for colorectal, lung, and cervical cancers. Controversies also exist with regard to the level of evidence required before screening for a disease is initiated. Even if there is a high level of evidence for efficacy and effectiveness, how the programme should be implemented needs careful consideration, particularly a clear understanding of benefits versus harms, potential or actual. In some countries, mass population screening programmes are implemented and in others, screening is dependent on access to health insurance. This chapter explores past and current screening activities among women for early detection and prevention of gynaecological cancers including cervical, ovarian, and endometrial cancers and discusses screening for vulval and vaginal cancer.

Childbirth trauma

Pelvic floor disorders are strongly associated with childbirth and are more prevalent in parous women. Pelvic floor trauma commonly occurs at the time of the first vaginal childbirth. Conventionally, childbirth trauma refers to perineal and vaginal trauma following delivery and the focus has been on the perineal body and the anal sphincter complex. However, childbirth trauma may involve different aspects of the pelvic floor. Pelvic floor trauma during vaginal childbirth may involve tissue rupture, compression, and stretching, resulting in nerve, muscle, and connective tissue damage. Some women may be more susceptible to pelvic floor trauma than others due to collagen weakness. Childbirth trauma affects millions of women worldwide. The incidence of perineal trauma is over 91% in nulliparous women and over 70% in multiparous women. A clinical diagnosis of obstetric anal sphincter injury (OASIS) is made in between 1% and 11% of women following vaginal delivery. Increased training and awareness around OASIS is associated with an increase in the reported incidence. Short- and long-term symptoms of childbirth trauma can have a significant effect on daily activities, psychological well-being, sexual function, and overall quality of life.

Contraception

Effective contraception is central to reproductive health and unintended pregnancies have a major negative impact on both maternal and child health. It is recognized that there is a global unmet need for effective contraception and often the unplanned pregnancy is terminated, sometimes by unsafe practices. There is recognition of the importance of accessible, effective fertility regulation both in the Millennium Development Goal 5b and now in Sustainable Development Goal 3. It is hoped that contraceptive provision will be expanded and made accessible to many women who previously were not able to address their fertility needs. The World Health Organization offers input and excellent clinical advice through the Medical Eligibility Criteria for contraceptive use which are regularly updated. It is recommended that these should be adapted for local use where appropriate. An understanding of the success of contraceptive methods with typical rather than perfect use is central to advising women and their partners on their contraceptive options. Attention to women with special needs such as those with medical disorders, young women, and women living with HIV must be central to any contraceptive service. Counselling should include discussing the risks and benefits of appropriate methods, the availability of emergency contraception, and the ongoing access to contraceptive counselling and reproductive health services. The aim of contraceptive service provision is to avoid unintended pregnancies and ensure that women feel empowered in the choices they make. Services providers are encouraged to provide a spectrum of contraceptive options which are accessible and acceptable to all clients.

Infertility

Human fertility is a complex process involving gamete production, fertilization, and implantation. Disruption of any of these key steps can result in infertility. Underlying lifestyle factors, age, or pathological conditions in either or both partners can be contributory. Traditional investigations can help to identify the nature of infertility. Management depends on modification of lifestyle factors and treatment of a specific cause—where appropriate. Assisted conception has transformed the approach to fertility treatment and is used for all cases of prolonged unresolved infertility. Individualized care, taking into account the chances of natural conception as well as the physical, emotional, and financial needs of a couple, is the basis of a successful management strategy.

Benign disease of the vulva

This chapter aims to enhance knowledge and skills in patient assessment, vulval examination, and treatment of vulval disease, specifically dermatological conditions and vulval pain. The prompt identification and treatment of vulval conditions can reduce anxiety, alleviate symptoms, and preserve an acceptable level of functioning for patients. Often simple measures can benefit the patient (e.g. use of emollients), but many have complex disease and can present with more than one condition so careful assessment and individualized management is essential. Combining treatment strategies is sometimes needed. Vulvodynia is not a skin condition but a chronic pain syndrome and is also covered in this chapter. It is important that health professionals work within their own competencies. Patients with complicated, rare, and treatment-refractory disease should be referred on to a vulval service for a multidisciplinary opinion.

Benign disease of the uterus

The benign diseases of the uterus compromise endometrial polyps, adenomyosis, and uterine fibroids or leiomyomas. Polyps are often asymptomatic, or may cause intermenstrual bleeding, and recent technological developments allow for rapid diagnosis (transvaginal sonography) and treatment (outpatient hysteroscopy and polypectomy with or without local anaesthesia). Precious little progress has been made over the past few decades in the understanding of the pathophysiology of adenomyosis, or its effective management beyond hysterectomy. Until as recently as two decades ago, the only treatment options for fibroids were hysterectomy and myomectomy, but the advent of radiological interventions (uterine artery embolization and focused ultrasound surgery) has revolutionized uterine-preserving management options of fibroid disease, while the recent emergence of selective progesterone receptor modulators has, at long last, heralded effective medical therapy for fibroids. This rapid expansion in fertility-preserving treatments for fibroids could not have been more timely since in recent years there has been a dramatic shift in the demography of childbirth, with many women postponing childbirth to their late 30s and early 40s, when fibroids are more prevalent and more symptomatic. Parallel developments in assisted reproduction technology now allow women to achieve pregnancies at an age that was unthinkable three decades ago. Even when child bearing is not an issue, hysterectomy no longer need be the only effective treatment for the menstrual disturbance and other symptoms associated with benign diseases of the uterus—new minimally invasive procedures now allow for equally effective interventions that improve women’s quality of life.

Hysteroscopy

Hysteroscopy (direct endoscopic visualization) of the endometrial cavity is an exciting and rapidly developing field of gynaecological practice. The most dramatic advances have occurred during the last 20 years due to technological advances including miniaturization of equipment and improved optics. Hysteroscopy is used both diagnostically and therapeutically to treat a wide range of gynaecological problems (heavy menstrual bleeding, infertility, and postmenopausal bleeding). The most recent advances allow accurate direct visualization of the uterine cavity which provides a platform for targeted biopsies, safe removal of endometrial polyps, and treatment of fibroids, septa, and adhesions. Proper training has resulted in a low incidence of serious complications. The current consensus is that hysteroscopy provides a gold standard not only for evaluating and treating intrauterine pathology but also for allowing a minimalist approach which has resulted in improved patient outcomes. This chapter provides an overview of the current state of this exciting and evolving field.

Pelvic inflammatory disease

Pelvic inflammatory disease is a sexually transmitted infection of the female upper genital tract. Rates of pelvic inflammatory disease have fallen in many countries over the last 10 years, at least in part due to increased screening for chlamydial infection. The clinical spectrum ranges from asymptomatic infection through to severe disease requiring hospitalization. Due to the non-specific nature of the condition, diagnosis can be challenging. All sexually active women presenting with acute lower abdominal pain should have a pregnancy test to rule out ectopic pregnancy. Treatment must be initiated as soon as the diagnosis is suspected and include antibiotics covering a broad spectrum of pathogens. Delay in diagnosis increases the risk of adverse sequelae including ectopic pregnancy and infertility. It is recommended that current and recent sexual partners receive empirical treatment, regardless of symptoms or microbiological results, and refrain from sexual contact until completion of therapy. Through better public understanding of the symptoms of pelvic inflammatory disease, women seeking earlier medical attention may reduce the risk of reproductive damage.