Health services providers should sensitize community members on symptoms of gynaecological cancer and advise them to seek help from health facilities. Women should also be encouraged to have routine annual gynaecological check ups by qualified health personnel. Health services providers should use simple cancer screening technologies such as visual inspection with acetic acid (VIA), visual inspection with Lugol’s Iodine (VILI), and breast examination. They should refer suspicious cases to higher levels for appropriate management.
Neoplasms may present as pelvic masses.
Ovarian Cancer
Clinical Features
Usually occurs in women aged 40 years and above. Usually presents late with mass in the lower abdomen.Pain and irregular vaginal bleeding are late features.
Ascites and wasting are further late features. In late cases the mass is usually irregular and fixed. Diagnosis is essentially clinical but confirmed with biopsy.
Investigations
Haemoglobin, blood group, urinalysis, blood urea.
Ul;trasound
Intravenous urogram (IVU)
Ascitic tap for cytology
Fine needle aspiration and cytology (FNAC)
Laparotomy for biopsy and histology and staging
Management
Surgery is the mainstay treatment. To prepare:
Improve general health with high protein diet and transfusion where necessary
Carry out palliative surgery in inoperable cases and staging.
Perform total abdominal hysterectomy and bilateral salpingo-oophorectomy in operable cases.
Administer chemotherapy in addition to surgery; available drugs include vincristine, vinblastine, alkeran, cyclophosphamide, and cisplatinum, as directed by the oncologist.
Admit level 4-6 for
Surgery and/or chemotherapy.
Confirmation of diagnosis.
Prevention
Annual pelvic examination and pelvic ultrasound are recommended as preventive measures for early detection and management.
Carcinoma of the Endometrium
Is probably the third commonest cancer in women in Kenya after cervix and breast. Min age is peri and postmenopausal. Associated with low parity, obesity, diabetes, and hypertension and may be preceded by endometrial hyperplasia due to unopposed oestrogen stimulation of endometrium. Presents with abnormal uterine bleeding at the perimenopausal or post-menopausal period.
Clinical findings may be unremarkable in early disease but enlarged uterus and evidence of metastasis may be evident in late cases. Diagnosis is confirmed by histology of endometrial biopsy obtained through MVA, fractional curettage, or Novak or Kevoorkian curette. Treatment is by extended total abdominal hysterectomy (TAH) but adjuvant chemotherapy and/or radiation may be needed in advanced cases. High doses of progesterone are especially useful in advanced disease.
Management
Management is by a gynecologist in conjunction with an oncologist.
Carcinoma of the Vulva
This accounts for 3-4% of all gynaecological cancers
Clinical Features
Majority of patients present after the menopause.
It may be preceded by pruritic conditions of the vulva.
Presents as an ulcer on vulva.
May have inguinal lymphadenopathy.
Diagnosis is by clinical features and confirmed by biopsy and histology.
Differential; diagnoses include granuloma inguinale, lymphogranuloma venereum, syphilitic chancre or gummata, and chancroid.
Management
Suspicious lesions should be referred to a gynecologist.
Treatment is by surgery (radical vulvectomy).
Extent of surgery will depend on the primary tumour.
Radiotherapy and chemotherapy and surgery for advanced disease.
Carcinoma of the Vagina
Accounts for 1% of gynecologist malignancies. Peak incidences are from age 45 to 65.
Clinical Features
There is post-coital bleeding, dyspareunia, watery discharge, urinary frequency or urgency, and painful defecation. Cancers are commonly found in the upper part of the vagina on the posterior wall. Speculum and digital examination reveals growth in the vaginal wall.
Investigations
Pap smear: Reveals carcinomatous cells
Schiller’s test
Biopsy.
Management
Depends on location and extent of the disease.
A tumour localized in the upper ⅓ of the vagina is treated either by radical hysterectomy with upper vaginectomy and pelvic lymph node dissection or with radium and external radiotherapy.
Treatment of secondary carcinomas and first degree carcinoma is usually combined and may be either radiotherapy or radical surgery. The 5-year survival rate without recurrence is about 30%.
Pelvic Inflammatory Disease(PID)
Pelvic inflammatory disease is an inflammation of pelvic structures above the cervical os. It is essentially a consequence of STI (gonorrhea and Chlamydia trachomatis), but can follow puerperal sepsis or abortion. Gonorrhea and Chlamydia trachomatis principally result in endosalpingitis, whereas puerperal and post-abortion sepsis result in exo salpingitis. PID may be acute, subacute, acute on chronic, or chronic. Tuberculosis is another important cause of PID.
Clinical Features
Acute PID is diagnosed by:
Lower abdominal pain usually starts soon after a menstrual period.
Fever.
Signs of pelvic peritonitis in the lower abdomen.
Bilateral adnexal tenderness and positive cervical excitation on vaginal examination.
The patient may be toxic with vomiting.
Chronic PID is diagnosed by:
Chronic or recurrent lower abdominal pains.
Dyspareunia,
Infertility.
Mucopurulent cervical discharge
Bilateral adnexal tenderness
Adnexal induration and/or masses (tubo-ovarian)
Diagnosis is mainly clinical.
Tuberculosis is diagnosed by biopsy: endometrial or pelvic.
Investigations
Urethral and cervical smears may be helpful in acute cases for Gram-stain and culture.
Hemoglobin.
BS for Mps
Urinalysis.
VDRL
Management
Acute PID: mild to moderate where the patient is not toxic and there are no features of peritonitis:
PO amoxicillin/clavulanate 625mg 12 hourly for 7 days OR doxycycline 100mg BD for 7 days 12 hourly with PO metronidazole 400mg 8 hourly for 7 days; avoid alcohol. Add PO ibuprofen 400mg 8 hourly and hyoscine butyl bromide 20 mg PO 8 hourly for 5 days.
STI related PID:
Amoxicillin 3g STAT + amoxicillin- clavulanate 625mg STAT +probenecid 1g + doxycycline 500mg QDS for 10 days. In pregnancy use erythromycin 500mg QDS for 10 days + metronidazole 400mg TDS for 10 days.
Acute PID-Severe cases with toxicity and features of peritonitis:
Start IV fluids.
Parenteral or oral analgesics, e.g., morphine 1o mg IM PRN(3 doses), then change to PO ibuprofen 400mg TDS for 7 days.
IV crystalline penicillin 3 mega unit 6 hourly OR ceftriaxone 1gm BD +IV gentamicin 80 mg 8 hourly + metronidazole 500 mg IV 8 hourly for 3-5 days. Then give PO metronidazole 400mg 8 hourly and doxycycline 100 mg 12 hourly for 10 days and PO ibuprofen 400mg 8 hourly for 5 days.
If fever persist after 48-72 hours of antibiotic cover:
Perform bimanual pelvic examination. Confirm with pelvic ultrasound.
If there is pelvic collection (bulge in pouch of Douglas) and/or adnexal masses, pelvic abscess is suspected and laparotomy for drainage done.
At laparotomy, do drainage and peritoneal toilet with warm saline; leave drain in situ for about 3 days and continue parenteral antibiotics postoperatively.
Chronic PID
Antibiotics as for mild to moderate acute PID.
Spouses or sexual partners are also investigated and treated for STI.
Physiotherapy for chronic pelvic pain.
Admit level 4 or above in presence of:
Severe PID, which is indicated by
Dehydration
Suspicion of abscess
Febrile patient
Suspicion of induced abortion
Acute PID if
There is vomiting
Follow up cannot be guaranteed
Patient Education
In case of partner(s), trace and treat contacts and advise condom use to avoid re-infection.