A short survey of our obstetrics and gynecology services

After breast cancer, cervical cancer is the most common female malignancy that is associated with younger age groups, or occurring more frequently in sexually more active women.

It would be ideal if each woman had a gynecological examination and a Pap smear once a year.

The latter is the most important test for prevention of cervical cancer, and its regular implementation reduces the risk of cervical cancer mortality for 90%.

Ultrasound examination either with an abdominal or vaginal probe makes part of any regular gynecological exam. It is done using either a half-curved abdominal probe placed on the abdomen of a lying patient having a full urinary bladder, or a cylindrical transvaginal probe inserted into the vagina of the patient with an empty bladder. The technique is used both in gynecology and obstetrics.

Transvaginal scanning enables the evaluation of normal pelvic anatomy: size, shape and echosonicity of the uterus; thickness and appearance of the uterine mucosa; size, shape and appearance of the ovaries, enlarged oviducts, if any, and the pelvic bottom. In dealing with sterility, ultrasound is used to monitor ovulation and the uterine mucosa in preparation for assisted reproduction. Ultrasound enables early detection of intrauterine pregnancy, and monitoring the fetal growth and development. Besides prenatal evaluation of fetal health, ultrasound also enables careful viewing of the placenta, amniotic fluid levels and the uterine cervix.

None the less, malignancies of other parts of the female reproductive system, the uterine body and ovaries in particular, are also a problem compared to cervical cancer. Ovarian cancer is one of the most malignant tumors in general, for which to the best of medical knowledge, there are neither effective control nor prevention.

Treatment options depend primarily on the spread of the disease. Surgical treatment alone will do only for early stage ovarian cancer (minimal tumor confined to one ovary). In all other cases, more complex therapy is required, and the effects are unpredictable. In this case, too, early detection plays a key role again. Fortunately, there is technology for early detection of ovarian cancer. Measuring blood flow to the ovaries, or tumor tissue using color Doppler adds to the ultrasound finding, especially to recognizing benign from malignant changes. If a result is suspicious, diagnostic testing will require supplemental techniques.

At our Polyclinic, color Doppler ultrasonography of the ovaries is a daily routine, which besides the tumor size, reveals its appearance and abnormal blood supply, too. The same technique can be successfully used for evaluation of the uterine body, thickness of its mucosa and any abnormality in its blood supply.

3D ultrasound is a medical ultrasound technique, often used during pregnancy, providing three dimensional images of the fetus. Often these images are captured rapidly and animated to produce a “4D ultrasound”.

Clinical use of this technology is an area of intense research activity especially in fetal anomaly scanning but there are also popular uses that have been shown to improve fetal-maternal bonding. 4D baby scans are similar to 3D scans except that they show fetal movement as shown in the video clip.

Due to the fact that the uterine cervix is an easily accessible organ to eye inspection, a worldwide known gynecologist Dr. Schivartche used to say that the uterine cervix reveals its illnesses by itself, and that one only have to learn to see.

The uterine cervix is visualized with a colposcope, a mobile instrument used to magnify and lighten the visual field.

Colposcopy is done after an abnormal Pap smear, and in the hands of our experienced gynecologists-colposcopists, it can recognize patients for control check-ups only from those who require further diagnostic testing and therapy.

A direct relationship between cervical cancer and human papilloma virus, the so-called HPV, and especially its high-risk types 16 and 18, has been confirmed. The rule that applies today is as follows: there is no cervical cancer without a HPV infection. There is no cure for the virus, although great success has been achieved by interferon vaginalettes as well as a recently developed vaccine.

Adolescents are at the highest risk as the virus might be transmitted to them from their infected partner. Their unprepared cervical epithelium tissue first reacts with an inflammation, and then it changes towards the early stages of cancer. These inflammatory and other abnormal cell changes are detected by the Pap test indirectly showing the presence of the infection. The virus itself is confirmed by the so-called genotyping technique. At the Eljuga Polyclinic, we therefore pay special attention to proper Pap screening and timely HPV typing to detect any changes as early as possible and thus allow their conservative, simple and effective treatment.

Many bacterial infections are also a common finding of a gynecological exam. Each of them is specific, and Clamydia trachomatis that requires special attention is detected by collection of a cervical swab sample to be cultured in a nutrient medium. This increasing infection, which occurs in the uterine and oviduct mucosa, is a common cause of female infertility and extrauterine pregnancy. In addition, it may cause spontaneous abortions and preterm deliveries. Isolation of this bacteria is therefore part of infertility treatment also provided by the Eljuga Polyclinic.

Both partners then receive appropriate antibiotic therapy. Control cervical smear should be taken three weeks after the completion of therapy.

Menopause is the final physiological bleeding from the uterus. Diagnosis is made retrospectively following the 6-12-month interval from the menstrual period absence. Menopause usually occurs between the ages of 45 and 50. It is a phase of a woman’s life when ovarian hormone production gradually declines and completely ceases.

Due to their menopausal symptoms, most of women refer to a gynecologist. More than 75% of them experience hot flushes and sweats that seriously affect their quality of life. The woman becomes emotionally labile that is frequently reflected in mood changes, anxiety and depression. Her skin is thinned and dry, and nails fragile. Vaginal dryness results in painful intercourse, and frequently recurrent urinary infections. Bones become fragile and vulnerable to fracture, and the incidence rate for heart attack and brain stroke increases.

The duty of the gynecologist is therefore to try to prevent all these changes, and get every woman acquainted with the advantages and drawbacks of hormone replacement therapy.

After missing the next period for only a few days, when pregnancy still cannot be detected by ultrasound, it is best to take a urine pregnancy test which will detect even the minimum level of betaHCG or the pregnancy hormone. The positive test should be confirmed by an ultrasound exam to establish the existence of a normal intrauterine pregnancy as the pregnancy test will be positive in case of an extrauterine pregnancy, too.

The first signs of a normal intrauterine pregnancy can be visualized on ultrasonography after missing the next period for a week only. Ultrasonography will then reveal just the presence of an intrauterine gestational sac without visualizing an embryo. The control check-up a week later should show an embryo and the onset of blood circulation. The growth and development of the fetus, amniotic fluid levels and condition of the placenta are followed by regular ultrasonography. Throughout a normal pregnancy, i.e. pregnancy without any complications, 4-5 ultrasound exams are recommended.

In case of any pregnancy complications, including fetal growth arrest, placental insufficiency, color Doppler of fetal vital organs is recommended as a useful tool in assessing the fetal risk. Depending on the results, the pregnancy then may be terminated early, either by induced labor or a Cesarean section.

After exclusion and possible treatment of a bacterial infection, abnormal Pap test results, CIN II and CIN III, require further testing. Following a previous colposcopy to localize the changes, target biopsy and cervical excochleation is required. The procedure is done on an outpatient basis under local anesthesia. Obtained material is then sent for pathohistological examination to confirm or refute the Pap test results and provide guidance for further management. If the procedure is done properly, the biopsy will also have a therapy value. After biopsy, a repeat Pap test should be done in 2 months.

Cytologic and pathohistologic evaluations of the cervical and uterine body mucosa obtained by curettage are the final step to reveal the presence of uterine malignancy, and we perform both of them within our institution. Besides suspicion of malignancy, other disorders and conditions, including irregular and abundant bleeding, are also an indication for this diagnostic and therapeutic procedure. If the procedure does not prove a sufficient therapy measure within the scope we can provide at our Polyclinic, we can arrange further treatment at one of the specialized hospitals, which is also a part of our continuing patient care.