Benign Gynaecological problems are important because they cause symptoms of offensive odour, irritation and sometimes pain. They are common problems and interfere with normal life. Many women often ignore their symptoms or try and treat themselves. There are many benign gynaecological conditions and they cannot all be covered in detail here. Some of these conditions include:
- Vaginal infections
- Benign ovarian cysts
- Vulval Dystrophy
It is self evident that all women will recognise that it is normal to have a vaginal discharge (Physiological). Occasionally the discharge is abnormal (Pathological).
Pathological vaginal discharge is usually associated with an offensive odour and colour and can cause discomfort. The type of vaginal infection can be suspected from history alone.
- Bacterial Vaginosis is usually associated with a heavy fishy vaginal odour.
- Candidiasis usually causes vaginal pruritis.
- Enteric bacterial infections cause discomfort and offensive discharge.
These infections are not usually serious but unfortunately they are common.
The vagina has a normal bacterial flora of healthy bacteria that create an environment where pathologic bacteria cannot survive. Any circumstance that destroys the normal bacterial environment will allow pathogenic bacteria to take over and infection will develop.
Recurrent or persistent vaginal infections are a great worry for patients.
They can occur if:
- The original diagnosis and treatment were wrong.
- The bacteria or fungus were resistant to treatment provided.
- The treatment was not long enough.
Reservoirs for persistent infection such as the bowel were not treated.
No attempt was made to re establish the normal vaginal bacterial flora.
Patient’s immune system is deficient making her more prone to infection.
History is very important and can certainly give a clue as to the type of infection.
Vaginal infections may be suspected but a diagnosis requires vaginal swabs.
They confirm the type of infection and determine the appropriate treatment.
Sexually transmitted diseases
Sexually transmitted diseases are extremely important.
STDs are reportable to the Health Department. and sexual partners need to be contacted. STDs can sometimes cause minimal symptoms initially but can cause ascending infection with potential damage to the fallopian tubes and pelvis.
STDs need to be suspected, investigated, diagnosed, treated and then reported.
Once diagnosed and treated an acute infection may never cause any further trouble.
If not diagnosed early and treated properly, an STD may cause relapsing symptoms of pain, which we call acute on chronic disease. Unfortunately an STD can cause persistent pain and chronic disease that usually requires a laparoscopy to diagnose and assess.
Benign ovarian cysts
Ovarian cysts often cause pelvic pain and are confirmed on ultrasound.
They are usually separated into two pathological groups:
- Physiologic ovarian cysts (always benign)
- Neoplastic cysts (Usually benign but sometimes malignant)
Neoplastic cysts, which are malignant, will not be discussed further.
Ovarian cysts are also described on their ultrasound appearance.
Simple ovarian cysts
They have a uniform echoic appearance on scan. They are usually benign but are not always physiological.
Complex ovarian cysts
Have an irregular appearance on scan with solid and cystic areas.
They are usually neoplastic but uncommonly malignant.
You may be right to think that all this sounds confusing.
How can we assess the nature of a cyst and decide on further management?
The initial appearance of the cyst may be diagnostic.
- What is the size of the cyst?
- Is the cyst unilateral or bilateral?
- Is the cyst simple in appearance or complex?
Does the cyst have any features which are themselves diagnostic such as a:
- corpus luteal cyst
- dermoid cyst or
Are there any complicating factors such as the presence of vascular nodules and increased or abnormal blood flow?
It is appropriate to perform further tests that might help make a diagnosis.
- Ovarian tumour markers
- Inflammatory blood test markers
Most importantly a repeat pelvic scan to see if the ovarian cyst has grown or showing signs of resolving.
It is not correct to operate on a benign physiological cyst that is showing signs of spontaneous resolution.
It is however also not correct to leave a patient with persistent pain.
In this situation it is appropriate to consider operating to remove the cyst.
If it is large it may be better to perform a mini laparotomy (open operation) to excise the cyst. Smaller ovarian cysts are often removed by laparoscopic surgery.
- It is very important that the laparoscopic surgeon is experienced.
- The cyst should be removed completely and not ruptured.
- Operative adhesions should be kept to a minimum.
- Hopefully the cyst does not recur.
In any situation where an ovarian cyst is believed to be potentially malignant it is best that such patients should be referred to a gynaecological oncologist!
Intense itchiness of the vulva and vagina is common.
It is often the result of vulva vaginal candidiasis and is easily treated.
Patients who have received multiple treatments for pruritis without success may have a vulval dystrophy. The skin is infiltrated with inflammatory cells and there is no clear reason why it occurs. It can be a chronic condition but it is amenable to improvement
Vulval dystrophy is divided into three groups:
- Hypoplastic Dystrophy.
- Hyperplastic Dystrophy.
- Mixed Dystrophy.
Hypoplastic dystrophy is often seen at the two ends of life. It is seen in children and older women. The skin is thin and fragile and the vulval labia become atrophic. The skin of the perineum adopts a pallor, which is called leucoplakia.
Initial treatment is often with oestrogen. If this fails testosterone may be effective.
Hyperplastic dystrophy is difficult to distinguish clinically from hypoplastic dystrophy. The skin is histologically thicker. It is important to be aware that hyperplastic dystrophy can undergo atypia which can progress to vulval cancer.
Initial treatment is usually with steroids.
If patients are experiencing intense itching which has not responded to previous treatments, it is necessary to get a diagnosis and this can only be done by performing vulval biopsies. These biopsies will enable a definitive diagnosis which can direct further treatment.
“It is wrong to put up with chronic vulval itching. It can ultimately become dangerous”.