Pathology evaluation

Endometriosis is a disease where the endometrium, that normally lines the inside of the uterus, is encountered outside the uterus.

Endometriosis is one of the most common causes of chronic pelvic pain and infertility.

We have been founding members of the Hellenic endometriosis society, where you can find more information about the disease, therapeutic approaches and support.

www.endomitriosi.org

Fibroids are non-cancerous growths that develop in the uterus.

A fibroid is made up from muscle fibers and fibrous tissue and is also called Myoma or Leiomyoma.

They are usually asymptomatic (i.e. cause no symptoms) and appear in women of reproductive age. It is the most common gynecological non-cancerous tumor, approximately 20-50% of women will have myomata in their lifetime.

What symptoms can they cause?

Fibroids are usually asymptomatic but they can cause:

• Heavy menses
• Abdominal pain
• Frequent urination
• Constipation
• Dyspareunia (pain on intercourse)
• Fertility problems

Why do fibroids occur?

While it is not clearly known what causes fibroids, it is believed that each tumor develops from an aberrant muscle cell in the uterus, which multiplies rapidly under the influence of estrogens. There is definitely a genetic component to it, since it is more common in certain racial groups like African Americans and in close relatives.

What are the types of fibroids?

Fibroids are categorized by their location.

• Submucosal: they are located beneath the endometrium and usually protrude in the cavity. This type of fibroids usually cause heavier bleeding during menses or in some instances fertility issues. They are usually removed with an endoscopic procedure called hysteroscopy.
• Intramural: they are located in the wall of the uterus, and unless they grow very big or distort the anatomy of the uterus they don’t cause any symptoms.
• Subserosal: they are located on the outside of the uterus and rarely cause any problems unless they grow very big or twist around their stalk when they are pedunculated, in which case they undergo necrosis and cause pain.

How are fibroids diagnosed?

Usually during a routine pelvic exam because they are asymptomatic most of the time.

Pelvic ultrasound either transvaginally or transabdominally can identify most of the fibroids and give us accurate information about the size and location of the tumors.

MRI is reserved only for multiple complex fibroids or if the consistency of the fibroids is heterogeneous.

What is the therapy for fibroids?
We only suggest intervention when the fibroids cause symptoms or if they might have implications on the patient’s fertility. Watchful waiting is the usual advice for patients with fibroids.

Myomectomy: The surgical removal of the fibroids. This can be done Laparoscopically, Hysteroscopically or via Open Laparotomy, depending on the size , location, number and off course the indication/difficulty of the surgery.

Hysterectomy: The surgical removal of the uterus, including the fibroids. This is usually reserved only for patients that have completed their childbearing and suffer from severe symptoms.

Uterine artery embolization: This is done by Interventional radiologists, where they insert a catheter and guide it to the main blood supply of the uterus and block the flow, leading to fibroid necrosis and shrinkage. This procedure is usually not done in women that wish to preserve their fertility and is not readily available in most hospitals.

Hormonal therapy: Since the growth of the fibroids is estrogen depended, hormonal therapy can reduce the size of the tumors but cannot be used for a long duration of time because it has all the side effects of menopause. It is used for short term control of the growth of the fibroids, most of the times pre- operatively.

What are the chances of cancer arising from a fibroid?

The chances of getting leiomyosarcoma (cancer) when you have a fibroid are extremely low. Most studies calculate the risk in being below 1 in a thousand.

This is the reason why we don’t remove them if they do not cause any problems.

Ovarian cysts are fluid filled sacs that originate from the ovary and are usually asymptomatic.

There are two types of cysts:

• Functional cysts: they usually form when the follicle of the menstrual cycle does not rupture. They are benign and short lived. These are the most common ovarian cysts
• Pathological cysts: these are a result of abnormal cell growth or another pathological condition. They are not very common.

How are they diagnosed?

They are usually an incidental finding on a pelvic ultrasound or other imaging modality.

Ultrasound is the preferred method for diagnosis of ovarian cysts, since it can give us a lot of information about the size, position and nature of the cyst. They are usually followed with a repeat ultrasound exam to clarify the nature of the cyst.

If a cyst is suspicious for malignancy then cancer markers can be done with a blood test. It is important to stress out that Cancer markers can be high in non-cancerous situations like endometriosis or pelvic inflammation, so it does not necessarily means that you have cancer.

How are they treated?

Most functional cysts do not need treatment because they disappear on their own.

Some pathological cysts might need to be removed. Surgical removal is usually done laparoscopically. In certain situations open laparotomy might be needed.

They are usually an incidental finding on a pelvic ultrasound or other imaging modality.
Ultrasound is the preferred method for diagnosis of ovarian cysts, since it can give us a lot of information about the size, position and nature of the cyst. They are usually followed with a repeat ultrasound exam to clarify the nature of the cyst.
If a cyst is suspicious for malignancy then cancer markers can be done with a blood test. It is important to stress out that Cancer markers can be high in non-cancerous situations like endometriosis or pelvic inflammation, so it does not necessarily means that you have cancer.

HPV is a virus (Human Papilloma Virus) that affects the skin and the mucosa (moist areas). There are more than 100 types of HPV, and approximately 30 of those affect the genital area.

It is the most common sexually transmitted disease. The chances of being exposed are high.

What does the HPV cause?

• Genital warts: or else condylomata accuminata are external skin growths of whitish discoloration in the genital region that can be single or accumulate in “cauliflower” like structures.
• Cervical dysplasia: is an atypical appearance of the cells lining the cervix and if it progresses it can lead to cervical cancer in several years.

How can I prevent HPV infection?

HPV is transmitted by sexual intercourse or skin to skin contact of the genital areas. Condom use decreases significantly the chances of transmission. The HPV vaccine gives immunity towards most of the HPV infections and is recommended for administration by most countries before commencing sexual intercourse. It has been shown that women with multiple sexual partners have higher chance of getting an HPV infection.

How much protection does the HPV vaccine offer?

The HPV vaccine offers more than 70% protection for cervical cancer and even greater protection for genital warts.

Is the HPV vaccine safe?

The vaccine is safe and efficient. It has been on the market for more than 10 years and several studies have looked at the side effects proving its safety. The only side affects you can get are, as in most vaccinations, local irritation, pain, fever or rarely an allergic reaction.

How can I be tested for HPV?

Genital warts: can be diagnosed by self-examination if you notice unusual growths or by your gynecologist in the annual exam by inspecting the area.
Cervical dysplasia: is diagnosed with screening tests like the Papanikolaou (Pap) smear on your annual Gyn exam. The frequency of examination depends on your age.

Does HPV cause cancer?

Yes, but luckily very few people from those exposed to HPV will eventually get Cancer.
Low grade atypia in young healthy population reverts to normal on its own in most of the cases (more than 70%).

Can I prevent cervical cancer?

Having had the vaccine and having cervical cancer screening with Pap test can prevent almost all cases of cervical cancer. This way we can identify precancerous lesions, years or even a decade before the actual cancer occurs.

How can I treat HPV infections?

Genital warts: they are usually treated with excision of the lesion and occasionally local destruction with creams/ointments, thermoablation (laser or electrocautery) or cryoablation.
Cervical dysplasias: the depth of the lesion is determined with colposcopic biopsies and then the appropriate therapy is suggested. Which could range from observation or ablation in mild cases and excision of the external portion of the cervix (cone biopsy, LEEP).

Endometrial polyp is a local overgrowth of the cells lining the uterine cavity. They are usually benign. Occasionally at older ages they can become precancerous or cancerous.

What are the symptoms?

They can cause heavier menstrual bleeding and intermenstrual bleeding (bleeding in between menses). In some cases they can cause infertility by preventing the implantation of the embryo.

How are they diagnosed?

They are usually diagnosed by transvaginal sonography. In difficult cases the diagnosis can be placed with saline infusion hysterography or office hysteroscopy.

How are they treated?

Because of their benign nature, watchful waiting in low risk groups can be an option.

If the polyp persists, causes symptoms or is an infertility cause, then removal is suggested.

They can be removed with D&C (Dilatation&Curettage) but because of the risk of leaving behind part of the polyp, hysteroscopy is the preferred method nowadays.

Hysteroscopy gives us direct visualization of the endometrial cavity and more precise instrumentation and sampling, whereas D&C is a blind procedure that cannot be that delicate.

Hysteroscopy is a minor endoscopic procedure of minimal duration and you can leave the hospital a few hours after the procedure and return to your usual everyday activities.

Cervical polyp: is a similar growth in the cervical canal. They are also benign in nature. Sometimes they protrude through the cervical canal.

They can cause bleeding during intercourse and intermenstrual bleeding.

If they protrude through the external cervical canal, then they can be removed at the office during the speculum exam with gentle twisting using a special clamp.

If they are located in the cervical canal then D&C or Hysteroscopy might be needed.

These are malformations in the development of the embryologic precursors (Mullerian ducts) of the uterus, salpinges and the part of the vagina. They are also called Mullerian duct anomalies.

The incidence ranges from 0.5 to 3.0% in the general population and is slightly higher in the infertility population (3-6%).

Embryologically the Mullerian ducts undergo elongation, fusion and canalization from 6 to 10 weeks in utero. Any problem in these processes can result in malformation.

There is a whole range of malformations that can occur, ranging from inconsequential malformations like arcuate uterus to complete agenesis (absence) of the uterus or duplication of it.

Mullerian duct anomalies are often related with kidney anomalies and vertebral problems. This is why once you have the diagnosis, you have to investigate the renal system along with the vertebral column.

How is it diagnosed?

Most uterine malformations are an incidental finding during a pelvic sonogram. Sometimes the symptoms can lead you to the diagnosis.

MRI is usually ordered to further specify the diagnosis if it is intricate.  Diagnostic laparoscopy is rarely needed these days.

Investigation of the renal system and spine is usually granted.

 How are they treated?

They usually don’t require any treatment. In severe cases, surgery might be needed.

It is the involuntary leaking of urine. Incontinence can range from a few drops to complete emptying of the bladder.

What are the types of urinary incontinence?
Stress urinary incontinence (SUI): leaking of urine when extra abdominal pressure is applied, like in sneezing, coughing, laughing or in certain activities.

Urge Incontinence: is a sudden onset urge to urinate that is hard to stop. Women with this type of incontinence may leak urine on the way to the bathroom.

Mixed incontinence: combines symptoms of both.

How is the type of urinary incontinence diagnosed?

• Urine analysis: is always requested because a Urinary infection can mimic incontinence symptoms sometimes.
• Medical history: your gynecologist will ask you several questions about the signs and symptoms of your condition and may have you fill in a bladder diary for several days.
• Physical exam: the doctor will examine you to see if you have pelvic organ prolapse and may ask you to perform some test like “cough test”.
• Urodynamic testing: reserved for the cases where the diagnosis is not clear, it is a specialized test using a urinary catheter and electrodes to collect data about several measurements.

How is urinary incontinence treated?

Depending on the type of incontinence we usually start with lifestyle modifications like decreasing the amount of water intake or performing certain exercises (Kegel) and then proceed to medications, pessaries or surgical correction of the incontinence.

Vaginal prolapse is a condition where the bladder, uterus, rectum or small bowel prolapse (fall out of their normal position) into the vagina or sometimes out of the introitus.

What are the types of prolapse?

Cystocele: when the bladder prolapses, creating a bulge in the anterior vaginal wall.

Rectocele: when the rectum prolapses, creating a bulge in the posterior vaginal wall.

Enterocele: when the apex of the vagina drops, containing usually loops of small bowel covered by the vaginal wall.

Uterine prolapse: when the uterus prolapses in the vaginal canal.

There are four stages of uterine prolapse:

• First degree: the uterus drops in the vaginal canal but not up to the introitus.
• Second degree: the uterus drops all the way to the introitus.
• Third degree: the uterus is visible outside the introitus.
• Fourth degree: the entire uterus in outside the vagina.

What causes vaginal prolapse?

When the supporting muscles and tissues relax or get traumatized.

This can happen with age, especially after menopause but can result after child birth because it can traumatize the surrounding tissues. Also sometimes it can happen after hysterectomy because of lack of proper support.

How is vaginal prolapse treated?

There are certain exercises that can help strengthen the supporting muscles of the vagina, but in more severe cases we can use pessaries or even surgery.