Specific Gynecological Pathologies

Specific Gynecologic Operations

• Hysterectomy: removal of the uterus.
• Radical hysterectomy: removal of uterus, tubes, ovaries, associated lymph nodes, and supporting connective tissue (for malignancy).
• Subtotal hysterectomy: removal of the upper uterus while leaving the cervix intact
• Myomectomy: removing a fibroid tumor from the uterus, sparing the uterus.
• Oophorectomy: removal of the ovary.
• Ovarian cystectomy: removing a cyst of the ovary.
• Salpingectomy: removal of the fallopian tube.
• Salpingostomy: opening of the fallopian tube.
• Dilation and Curettage (D&C): scraping the uterine lining to retrieve, clear, or study the tissue.
• Dilation and Extraction (D&E): typically, an elective abortion (pregnancy termination).
• Mastectomy: removal of the breast. Although this is considered "female" surgery, it really isn't "gynecologic," since it is done by general surgeons and not gynecologists.

NOTE: Removal of the entire uterus, cervix, fallopian tubes, and ovaries would be called a “total hysterectomy/bilateral salpingo-oophorectomy,” not a "total hysterectomy," which is a common misconception of terminology. When it includes lymph nodes and other lymphatic vessels and supportive tissues ("parametrium"), this makes it a "radical hysterectomy."  

Ovarian Cysts

A cyst is a fluid-filled sac that can develop in the ovaries. Most women experience a cyst of their ovaries during life, because cysts are typically just variations of egg follicles.

A follicle (in the monthly ovarian cycle) has fluid surrounding its maturing egg until ovulation, when the egg is released and the fluid escapes. The difference between a follicle and a cyst is semantic and merely arithmetic. If it is > 2 cm. diameter, it is then deemed a "cyst," but it is still a follicle, technically, which ovulation will "cure."

Such cysts that are follicles are called "follicular cysts." Sometimes follicular cysts are delayed in ovulating or even fail to ovulate, which can extend the first half of the cycle, and thereby, postpone the second half of the cycle and the menses to follow. This is the proverbial "late" period that can produce a negative pregnancy test.

After ovulation, if fluid is trapped in the remnant of a follicle--that is, in the corpus luteum--it is called a "luteal cyst."

Most ovarian cysts cause no symptoms or pain and are just found during routine exams.

Assessment may identify bleeding that is inconsistent with the patient’s normal menstrual cycle and/or pain that is most likely reported on only one side of the pelvis.

A ruptured ovarian cyst may cause vaginal bleeding and is often associated with pain: an enlarged cyst is painful on that side, but once rupture occurs and there is bleeding, the sharp unilateral pain is replaced by a vague burning sensation throughout the pelvic area. This type of bleeding and its associated discomfort is typically temporary and self-limited. Rarely, it can result in brisk internal hemorrhage.

In the field, ruptured ovarian cysts may be confused with ruptured ectopic pregnancies, which can be a significant--even life-threatening--danger to the patient. Management includes

• proper patient positioning,
• oxygen administration if necessary,
• adequate support of the ABC’s,
• pharmacologic treatments if necessary, and
• transport to definitive care.

The bleeding of either an ectopic or ruptured ovarian cyst cannot be controlled, as this is an internal process that warrants transport for adequate (possibly surgical) evaluation.

Ovarian Torsion

An ovarian torsion is an infrequent but significant cause of unilateral, lower abdominal pain.

The ovary hangs on a stalk and it is possible for this stalk to twist upon itself. Rich in nerve endings, its twisting causes severe pain. Since the blood supply to and from the ovary also is through this stalk, twisting will obstruct both arterial blood supply into--and venous drainage out of--the ovary. An ovarian cyst that would naturally weigh more than just an ovary can put undue strain on the stalk, causing it to twist into a torsion. Torsion risks death of the ovary and is a surgical emergency.

Any unilateral severe pain in the lower abdomen could represent torsion, which is a gynecological emergency because if it lasts long enough, the woman could lose her ovary from the ischemia and resulting necrosis.

When it occurs on the right side, it can be confused with appendicitis, which in the field is irrelevant, since both warrant transport. Management includes

• proper patient positioning,
• oxygen administration if necessary,
• adequate support of the ABC’s,
• pharmacologic treatments if necessary, and
• transport to definitive care.

Endometriosis

Endometriosis is a condition in which there is endometrial-like tissue outside of the uterus.

Since the lining of the uterus is hormonally reactive--building up, maturing, and sloughing, based on the hormonal cycle--this presents with pelvic pain since, unlike menses, the menstrual debris of internal endometriosis isn't discarded out of the body, but remains in the pelvis in repetitive inflammatory cycles. Most patients you will see who have endometriosis will report a history of it, making it reasonable to assume the pain, which usually coincides with menses, is part of the disease's presentation.

NOTE: The pelvis is not the only place where endometriosis can be. It has been reported in the umbilicus, nose, and lungs, which cause monthly bleeding at the umbilicus or from the nose, and hemoptysis from the lungs. It has even been found in the brain, which can provoke monthly stroke-like symptoms.

Mid-Cycle Pain (Mittelschmertz)

ACHTUNG! While endometriosis causes pain during the menstrual phase of the cycle, some women experience the pain of ovulation, occurring at mid-cycle, especially if the follicle is large enough to be a cyst (> 2 cm.). This is called "Mittelschmertz" pain and is hallmarked by being unilateral and mid-cycle. This name is from the German, "middle pain," referring to the mid-cycle sensation of ovulation in some women able to discern it: that is, it is the pain of ovulation.

♦ CALL TO ACTION: Transport is necessary for Mittelschmertz because imaging studies are needed to make sure it is not appendicitis (if on the right) or an ectopic pregnancy (which can be on either side).

Dysfunctional Uterine Bleeding (DUB)

Dysfunctional uterine bleeding is irregular uterine bleeding that occurs due to hormonal dysfunction in the cycle.

For example, if there is a delay in ovulation, a woman may be "stuck" in the first half of the cycle, until the lining of the uterus, which has continued to build up but not mature, begins to shed in an irregular fashion.

As such, DUB reflects a disruption in the normal cyclic pattern of post-ovulatory hormonal maturation (from progesterone) to the endometrial lining.

If a uterus is pathologically enlarged, there is more "real estate" to bleed, and the bleeding can be profuse.

Management includes

• proper patient positioning,
• oxygen administration if necessary,
• adequate support of the ABC’s, and
• pharmacologic treatments if necessary.

Unfortunately, the bleeding cannot be controlled until transport to definitive care.

Leiomyomata

UTERINE FIBROIDS ("leiomyomata"; singular, "leiomyoma") are benign, space-occupying fibrous swirls of tissue that are embedded in the muscular layer of the uterus.

Normally, near the end of menses, the bleeding of the "period" lessens by two mechanisms:

1. There is only so much tissue to shed, and bleeding diminishes as the amount of tissue left is decreased, and
2. Muscular contraction will "scrunch" down the open, bleeding areas from which the endometrium shed.

Fibroids are not muscle, so they interfere with the muscular contractions (Step 2, above) to stop the bleeding. Because of fibroids, uterine bleeding of any kind can progress into a hemorrhagic emergency.

Management includes

• proper patient positioning,
• oxygen administration if necessary,
• adequate support of the ABC’s, and
• pharmacologic treatments if necessary.

Unfortunately, the bleeding cannot be controlled until transport to definitive care, so hypovolemia/hypotensive management may be necessary.

Uterine Prolapse

A prolapsed uterus is a condition wherein the pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus, allowing the uterus to slip down into or protrude out of the vagina. 

A prolapsed uterus may present with moderate to severe pain and may or may not present with vaginal bleeding. The prolapse itself is not part of a bleeding process, but if there is bleeding, management includes

• proper patient positioning,
• oxygen administration if necessary,
• adequate support of the ABC’s,
• pharmacologic treatments if necessary, and
• transport to definitive care.

The uterus "hanging out" of the vagina is more distressing to the patient than it is dangerous; however, this displacement displaces the peritoneal covering over the uterus, too, and can cause severe vagal reactions--

• hypotension and
• bradycardia

"Nearly one-half of all women between ages 50 and 79 have some degree of uterine or vaginal vault prolapse, or some other form of pelvic organ prolapse."  - Uterine Prolapse Article - Johns Hopkins University

Foreign Bodies

Foreign bodies may be present in the vagina due to intentional sexual acts, forgotten tampons, loss of condoms during intercourse, or due to malfunctioning medical devices (IUD--intrauterine contraception device).

Bleeding due to foreign bodies in the vagina may by moderate to severe and may or may not present with pain. A detailed past medical history is usually revelatory.

Management includes

• proper patient positioning,
• oxygen administration if necessary,
• adequate support of the ABC’s,
• bleeding control,
• pharmacologic treatments if necessary, and
• transport to definitive care. 

You should not attempt to remove the foreign body, even if it is partially exposed.

Toxic Shock Syndrome (TSS)

Occasionally a woman will forget she has a tampon in, and this will grow bacteria and accumulate inflammatory, even purulent, secretions that may present as a bloody vaginal discharge.

This source of bacterial seeding can have systemic ramifications, advancing the emergency from mere foul vaginal odor to toxic shock syndrome sepsis. If there is

• fever,
• lethargy, or
• severe pain associated with a foul odor

--with or without bleeding, transport to definitive care is indicated.