Besides bimanual pelvic examination, the Pap smear, endometrial biopsy and ultrasound examination are important investigations performed in primary care.
A significant share of benign gynaecological tumours and lesions are asymptomatic and detected incidentally on clinical examination.
External genitals
There is great variation in the normal anatomy of the external genitals.
Asymmetry or large size of the labia minora (labial hypertrophy), for example, is common.
Similar benign skin lesions occur on the external genitals as elsewhere on the skin, such as naevi, seborrhoeic keratosis, haemangiomas, molluscs, skin tags.
Urethral caruncles are common findings in postmenopausal women.
A Bartholin's gland may be infected (bartholinitis), or the duct may become obstructed, leading to the formation of a Bartholin's duct cyst.
Various kinds of ulcers can be found on the external genitals.
Genital herpes is a common cause of ulceration on the external genitals.
Candidiasis may cause small fissures in the area of the external genitals.
Lipschütz ulcer is a rare, self-limited ulcer associated with a respiratory tract infection, occurring in young women.
Certain dermatological diseases cause ulceration (e.g. lichen sclerosus et atrophicus and lichen ruber planus).
The possibility of cancer should be kept in mind particularly in the case of poorly healing ulcers.
Many dermatological diseases (especially eczemas, psoriasis, neurodermatitis) occur on vulvar skin.
Lichen sclerosus et atrophicusLichen Sclerosus is an inflammatory dermatological disease occurring particularly on vulvar skin.
Lichen ruber planusLichen Planus is a common inflammatory disease of the skin and mucosa that may in rare cases occur on the external genitals and/or in the vagina.
If differential diagnosis presents problems, do not hesitate to take a biopsy; this can most conveniently be done with a punch under local anaesthesia. Patients with prolonged symptoms or symptoms responding poorly to treatment should be referred for assessment by a gynaecologist.
Labial hypertrophy
There is increasing focus on the appearance of the female external genitals, and any deviation from the standard makes patients worry.
Labial hypertrophy means large labia minora but there are no diagnostic criteria available for this. Half of asymptomatic women have larger labia minora than labia majora, i.e. this is often a normal variant.
Labial hypertrophy may cause irritation or pain when playing sports or in vaginal intercourse, for example.
If a patient worries about the anatomy of her external genitals, this should be discussed carefully with her, reminding her about the wide normal variation. She should be given basic instructions for taking care of the area of her external genitals.
Labial hypertrophy is very rarely an indication for surgical treatment in public health care. If it is indicated, this should be discussed extensively and multiprofessionally, particularly in the case of young women.
Urethral caruncle
A topical oestrogen product can be prescribed for the treatment of an urethral caruncle (see Picture 1), as necessary.
Large symptomatic caruncles require treatment by a urologist.
A urethral tumour should be considered in differential diagnosis.
Bartholinitis
Bartholinitis is a mixed infection caused by aerobic and anaerobic bacteria. Bacterial culture is rarely useful for the diagnosis. Gonorrhoea and chlamydia samples can be taken for differential diagnosis.
In mild infections, purulent discharge is the only symptom. However, infection often leads to obstruction of the gland duct and the formation of a painful abscess in the area of the gland situated in the vestibule of the vagina at 5 or 7 o'clock. The abscess makes sitting and walking difficult. There may be fever as a general symptom.
At an early stage, when the abscess is not mature yet, the inflammation can be treated with antimicrobial drugs.
1st generation cephalosporin (cephalexin) 500 mg 3 times daily and metronidazole 400 mg 3 times daily for 5-7 days
A fluctuant and mature abscess should be incised and drained from the mucosal side under local anaesthesia, usually in specialized care. A Word catheter is very suitable for draining the abscess. Antimicrobial medication is often used even though incision of the abscess alone may be sufficient.
In 5-15% of patients, the abscess will recur or a duct cyst will form after incision and drainage. In repeatedly recurring cases, marsupialization (incision of the cyst and folding and suturing its edges so as to leave the cyst open) or surgical excision of Bartholin's gland should be considered.
In differential diagnosis of bartholinitis, inflamed haematoma on the external genitals, inflamed paraurethral gland (Skene gland), perianal abscess Anal Abscess and cancer of Bartholin's gland should be considered.
Cancer of Bartholin's gland is rare, occurring mostly in postmenopausal women. An abnormal gland is solid, not fluctuant.
Bartholin's cyst
In Bartholin's cyst, the gland duct is obstructed but the gland is not inflamed (Picture 2). A cyst may represent a sequela of bartholinitis or of episiotomy, trauma or other ductal injury, for example.
Asymptomatic cysts need not be treated.
If the cyst causes symptoms, disturbing intercourse or physical exercise, for example, it can be treated with a Word catheter or by marsupialization.
If it recurs, cystectomy can be planned, as necessary.
Candida vulvitis
Itching, smarting and pain of the external genitals are typical symptoms of Candida vulvitis.
Candidiasis of the external genital skin does not always involve abnormal vaginal discharge, which is typical for vaginal candidiasis.
Clinical findings include diffuse erythema of the vulva and small ulcers particularly between the labia majora and minora and in the perineal area. Coating associated with candidiasis is rarely found on the external genitals.
The diagnosis can usually be made on a clinical basis.
Yeast culture of leucorrhoea can sometimes be used to support the diagnosis. The result must be interpreted with caution: on one hand, a negative vaginal culture will not exclude candidal vulvitis and, on the other hand, a positive culture does not necessarily mean that the symptoms are due to yeast.
Bacterial culture can be used for differential diagnosis if the symptoms are also consistent with a Streptococcus A infection.
Treatment can be started based on clinical suspicion.
The same products can be used as for candidal vaginitis Vulvovaginitis but, depending on the severity of the clinical picture of candidal vulvitis, longer treatment than those used for candidal vaginitis will mostly be needed.
Genital lichen ruber planus
Occurs rarely on external genitals and/or in the vagina
Most cases of genital lichen ruber planus are of the erosive, or ulcerative, subtype.
It causes pain, smarting or itching.
Vaginal disease usually involves abnormal discharge. Dyspareunia is common.
Erosive lichen ruber planus of the external genitals causes a clearly defined red area (‘erosion') at the vaginal orifice; in vaginal disease, similar lesions can be seen on the vaginal mucosa. Scarring of the external genitals and vagina is common.
Diagnosis and treatment are challenging; do not hesitate to refer the patient to specialized care.
The diagnosis can be made based on clinical and histological findings. Treatment is based on continuous topical treatment with a corticosteroid ointment supplemented with systemic treatments, as necessary. Scar complications can be treated operatively, as necessary.
Lichen ruber planus may also occur in areas other than the genital area, particularly on the oral mucosa. The patient should be asked about any symptoms in other areas of the skin or mucosa consistent with lichen ruber planus, and targeted examinations should be performed as indicated by such symptoms.
Vaginitis/vaginosis Vulvovaginitis and vulvodynia Vulvodynia should be considered in differential diagnosis.
Vagina
The vaginal mucosa is sensitive to hormonal changes.
At low oestrogen levels (postmenopausal women, lactating women), mucosal atrophy is common.
Vaginitis is a common complaint. Candidal vaginitis and symptomatic bacterial vaginosis, in particular, should be recognized and treated in primary health care (see Vulvovaginitis).
Lesions caused by HPV, such as condylomas (see Human Papillomavirus (HPV) Infection), are rather rare in the vagina and usually completely asymptomatic.
Lichen ruber planus may occur on the vaginal mucosa as erosive, bleeding, red lesions. It may lead to cicatricial stricture of the vagina (see above).
Vaginal cysts (Gartner's duct cysts) are mobile mucosal lesions with smooth surface that are often detected incidentally.
Blueish nodules consistent with endometriosis are occasionally but rarely seen in the vagina (see Endometriosis).
In uterine prolapse, either the ectocervix (the vaginal part of the cervix) or the vaginal mucosa protrudes from the vagina (see Gynaecological Prolapses).
In the case of unclear vaginal symptoms and findings (such as increased abnormal leucorrhoea, unusual bloody vaginal discharge or postcoital bleeding), a Pap smear should be taken Dysmenorrhoea.
Mucosal atrophy
Mucosal atrophy may cause symptoms including dryness, itching, smarting and dyspareunia. Atrophic mucosa is thinned and erythematous.
This is extremely common in postmenopausal women.
If there are vaginal symptoms, in many cases a trial with a topical oestrogen is warranted.
A topical oestrogen product (oestradiol or oestriol) should first be used every night for one week. Maintenance treatment should subsequently be used on 2 nights a week.
For patients with a history of breast cancer, the treatment should be used only after due consideration, and a product containing oestriol should be chosen.
Vaginal cyst
A vaginal cyst is a rare finding. It may be asymptomatic or complicate vaginal intercourse or the use of tampons. A cyst can be felt as a bulge on bimanual pelvic examination.
Patients with symptoms should be referred to specialized care.
Uterine cervix
In young women, after childbirth, and in users of hormonal contraception, the squamocolumnar junction, i.e. the border between the glandular (columnar) epithelium of the cervix and the stratified squamous epithelium of the vagina is seen as ectopy in the ectocervix. The finding is sometimes also called cervical erosion.
A Nabothian cyst is an epithelial lump caused by occlusion of a glandular duct; it requires no treatment.
A polyp is a benign mucosal lump on the uterine cervix.
As in the vagina, condylomas associated with HPV infection may be seen but most precancerous and other lesions caused by human papillomaviruses are invisible to the naked eye (see Human Papillomavirus (HPV) Infection).
In the case of unclear cervical lesions, a Pap smear test should be done Pap (Cervical) Smear and Endometrial Biopsy. If clinical examination cannot exclude cancerous growth, the patient should be referred to specialized care.
In that case, do not wait for the Pap smear result.
Ectopy (erosion)
This is a normal finding not requiring any treatment or follow-up.
Postcoital bleeding may sometimes be due to extensive ectopy. Recurrent postcoital bleeding warrants colposcopy. The urgency of colposcopy depends on Pap smear results. Samples to test for chlamydia and gonorrhoea should also be taken.
Bleeding often subsides with time. Loop electrosurgical excision is very rarely resorted to.
Polyps
A polyp may cause postcoital bleeding or may be detected as an incidental finding.
A polyp can be removed by twisting with forceps. An asymptomatic, small (< 5 mm) polyp does not need to be removed. The removed tissue should be sent for pathological examination (PAD).
Lesions of the uterine corpus often cause abnormal bleeding. In the case of abnormal uterine bleeding, an endometrial biopsy should be readily taken from the uterine cavity (see Pap (Cervical) Smear and Endometrial Biopsy).
A Pap smear should also be taken, as necessary and, for differential diagnosis, in premenopausal women, a pregnancy test should be performed and samples taken for chlamydia and gonorrhoea tests.
Myomas (fibroids) are benign smooth muscle tumours of the uterus that are found in as many as half of women of fertile age, most often in those aged 40-50 years.
Endometrial polyps are a relatively common finding in postmenopausal women, in particular.
Excess growth of the uterine mucosa, or endometrial hyperplasia, is due to excessive action of oestrogen or deficient or short-lived action of progesterone. It usually occurs in premenopause.
In adenomyosis, endometrial-type tissue grows into the myometrium. Adenomyosis often occurs in association with endometriosis (see Adenomyosis).
An ultrasound examination should always be done and endometrial biopsies taken to find out the cause of bleeding in the postmenopausal period or during hormonal replacement therapy Pap (Cervical) Smear and Endometrial Biopsy.
Myomas
Most myomas are located in the uterine corpus (Picture 3) and are symptomless. Any symptoms are associated with their size and location.
Submucous myomas (15%), which grow under the mucous membrane of the uterus, cause heavy bleeding followed by anaemia. Saline solution injected into the uterine cavity (sonohysterography) can be used to confirm the size and location of a submucous myoma.
Large intramural and subserosal myomas may cause pressure symptoms and pain in the pelvis, irritate the urinary bladder and disturb bladder or bowel function.
A pedunculated myoma may twist around its stalk, become gangrenous and later calcify. It can be difficult to differentiate between a pedunculated myoma and an ovarian tumour by ultrasonography.
An enlarged uterus feeling dense but mobile on bimanual palpation suggests myomas. A myomatous uterus may also feel rounded or clearly knobbly.
The diagnosis of myomas can be confirmed by vaginal or transabdominal ultrasonography. Myomas are often found incidentally on imaging (CT, MRI).
If imaging shows incidentally a smallish (< 5 cm), asymptomatic myoma, referral to specialized care is not necessary.
Symptomatic, large or rapidly growing new myomas should be examined in specialized care. The growth of myomas is often checked in a follow-up exam after 6-9 months (Picture 5).
A symptomless myoma does not require treatment or follow-up.
In only 0.1% of cases, are lesions considered myomas actually malignant leiomyosarcomas.
Large, rapidly growing and symptomatic myomas should be treated.
In abnormal bleeding alone, effective hormonal treatment may be sufficient (see article Abnormal Menstrual Bleeding). Do not hesitate to try a hormonal IUD.
Submucous myomas are particularly suitable for removal by hysteroscopy if most of the myoma grows towards the uterine cavity and its size is less than 4 cm (Picture 6).
Enucleation of myomas can be used in patients who wish to have children if myomas are considered to affect the chances of becoming pregnant. However, myomas seldom (< 2%) cause infertility. If the uterine cavity opens during the surgery, caesarean section is often recommended for future deliveries.
Abnormal bleeding that does not respond to treatment, or pressure symptoms due to a large uterus are an indication for hysterectomy.
New medication is constantly being developed for myomas.
An intramural myoma does not interfere with the course of pregnancy but, in every third woman, myomas will increase in size during pregnancy. As the uterus grows, stretching of the myoma may cause pain. In most cases, if the myoma grows during pregnancy it often decreases in size after pregnancy.
Polyps
Prolonged oestrogen action and lack of progesterone predispose the patient to the formation of endometrial polyps. Adjuvant anti-oestrogen therapy for breast cancer also increases the formation of polyps.
A polyp in the body of uterus can cause prolonged, heavy menstrual bleeding or spotting but is often found incidentally on gynaecological ultrasound examination.
Endometrial polyps are best diagnosed by ultrasound examination with saline solution used as a contrast medium injected into the uterine cavity (for injection of saline solution, see Gynaecological Ultrasound Examination).
If a polyp causes postmenopausal bleeding, an endometrial biopsy should always be taken. A biopsy is usually also taken if an asymptomatic polyp is suspected because in such cases the endometrium often appears thicker.
Symptomless endometrial polyps of less than 2 cm require no treatment (risk of cancer < 0.4%). However, all symptomatic and large (> 2 cm) polyps should be removed by hysteroscopy, usually in an outpatient clinic. Polyps are rarely malignant (1%), but endometrial hyperplasia does occur.
Endometrial hyperplasia causes prolonged profuse bleeding. It is usually detected in premenopause, when there is an increase in the number of anovulatory cycles.
The treatment of endometrial hyperplasia depends on whether the hyperplasia is non-atypical or atypical.
Non-atypical hyperplasia (N85.0) is the most common type and involves a low risk of carcinoma (1%). In premenopause, the treatment consists of continuous progestin therapy, either a hormone-releasing IUD Levonorgestrelreleasing Intrauterine System for Endometrial Hyperplasia or cyclic progestin (e.g. medroxyprogesterone acetate 10 mg or norethisterone 5 mg on days 15-24 of the cycle), as long as the patient has bleeding. The endometrial response should be evaluated by ultrasonography and biopsy after 4-6 months of treatment. If progestin treatment is unsuitable or insufficient for treating the bleeding, or if there are other particular indications for this, hysterectomy can be considered.
Atypical hyperplasia (N85.1) is treated by hysterectomy because it carries an increased risk of concomitant or subsequently developing endometrial cancer (29%). If the patient is young and wishes to have children or if hysterectomy is contraindicated, high-dose progestin can sometimes be used, strictly monitored by specialized care.
Ovaries
Most benign ovarian lesions are asymptomatic and detected incidentally in association with imaging.
Ovarian cysts are found in 5-10% of symptomless women of reproductive age and in 3-15% of menopausal women.
On clinical examination, asymptomatic ovarian lesions are often missed.
In women of fertile age, functional ovarian cysts, e.g. follicle cysts after unruptured ovarian follicles, and haemorrhagic corpus luteum cysts, are common. The use of a hormone-releasing IUD predisposes to functional cysts.
An endometrial cyst (endometrioma) is a finding associated with endometriosis (see Endometriosis).
Other benign ovarian lesions include benign epithelial tumours (serous, mucinous) and germ cell tumours (dermoids or mature teratomas). Some tumours are not just simple blebs but have a more solid structure.
Any mass felt adjacent to the uterus requires ultrasound examination Gynaecological Ultrasound Examination. Further treatment depends essentially on the size and appearance of the ovarian lesion, any symptoms caused and the patient's age.
A benign ovarian cyst is unilocular, anechoic and smooth-walled in ultrasonography.
A more solid, echogenic cyst in a woman of reproductive age, in particular, may suggest a teratoma, an endometrioma or a haemorrhagic lesion.
Abnormal features of an ovarian lesion include multilocularity, thick septa, rich blood supply, more solid tissue structure as well as a papillary mode of growth.
Ovarian lesions, such as sacto- and pyosalpinx Pelvic Inflammatory Disease (PID) or a pedunculated uterine myoma should be considered in differential diagnosis (see above).
Functional cysts
Asymptomatic unilocular cyst of less than 5 cm with no internal echoes (simple cyst) found incidentally in women of fertile age requires no action.
Larger cysts require either making a follow-up plan or surgical treatment in specialized care.
New ovarian lesions in postmenopausal women always require further investigations in specialized care.
Tumour markers (CA 12-5, HE4, inhibin) should be tested in specialized care, as considered necessary.
Sudden increasing pain, often unilaterally in the lower abdomen, is associated with a torsion of a cyst.
Perforation or rupture of a cyst causes sudden cutting pain. Cyst rupture may cause even profuse bleeding into the abdominal cavity, in which case emergency laparoscopy is needed to stop the bleeding.
Large cysts may cause a feeling of pressure, abdominal swelling, urinary frequency and bowel symptoms.
If the symptoms are suspected of being due to ovarian torsion or cyst rupture, emergency tests including basic blood count, CRP and clean-voided urine and, in women of fertile age, also hCG and samples for chlamydia and gonorrhoea, are indicated.
If torsion or rupture of a cyst is suspected, emergency referral to specialized care is indicated.
Other benign ovarian lesions
Abnormal structural findings in an ovarian lesion (such as septa, papillary growth) require further examination and often surgery regardless of the size of the cyst.
Tumour markers (CA 12-5, HE4, inhibin) are tested in specialized care, as considered necessary.
Large tumours cause a feeling of pressure, abdominal swelling, urinary frequency and bowel symptoms.
Symptoms and increased levels of tumour markers favour the decision to operate.
Ovarian lesions are usually removed by laparoscopy, either by enucleation (in women of fertile age) or by complete ovariectomy (in postmenopausal women or those with notably large lesions or if a borderline/malignant lesion cannot be excluded with certainty). Histological examination will confirm the final diagnosis.