Abnormal smears and colposcopy
A cervical smear is when a papanicolaou (pap) test is done by using a soft cervix brush to the surface of the cervix. This brush is designed like a Christmas tree in an attempt to take round cells of the cervix (squamous) as well as square cells of the cervix (columnar) so these can be tested in the laboratory under the process called liquid-based cytology (LBC).
The smear also tests for human papilloma virus (HPV) which is designed to triage into a fast-track yearly review or if negative then a three (3) yearly review as outlined by the National Cervical Screening Programme (NHSCSP).
An abnormal smear test is when the cells change colour, shape or both. The centre of the cell, called the nucleus, may appear darker and larger. This is referred to as dyskaryosis.
There are three types of dyskaryosis namely mild, moderate and severe. Any of these three require a colposcopy - a camera view of the cervix.
This is a simple procedure that is done in an outpatient setting or in a designated clinic area to view the cervix using a magnified lens called a colposcope. The time for the colposcopy depends on the grade of severity of the smear result and whether there is a human papilloma virus present or not. There are low risk HPV and high-risk HPV.
Usually, most colposcopy appointments are offered within 6 weeks from the date of the smear. Those with moderate or severe dyskaryosis are seen ideally within 2 weeks.
A cervical biopsy is a small pinch on the cervix and is usually performed at the colposcopy after a period of two minutes. This is to give time for the medical vinegar like solution called acetic acid 5% to be absorbed by the cervix after it is applied by the doctor onto the cervical surface.
There is a small degree of discomfort with the colposcopy procedure. A paracetamol tablet or two may be taken prior to the appointment to reduce discomfort.
The biopsy is sent to the laboratory and results are usually ready in 48 to 72 hours depending on the location of the clinic to the laboratory.
A follow up appointment is then arranged to determine whether the abnormal cells require further treatment or not.
The treatment is called a large loop excision of the transformation zone (LLETZ). This refers to the area where the round and square cells meet on the cervix. Treatment can be under local or general anaesthetic.
A test of cure (follow up appointment) is usually offered in 6 months from the date of treatment with a repeat smear to ensure that the smear comes back to normal and that daily work-life patterns can continue without any concerns.
Hysteroscopy
This is a procedure that involves passing a small 2.9mmm camera called a hysteroscope through the neck of the womb to check the inside of the womb known as the cavity. It can be done either while you are awake, or when you are asleep.
A hysteroscopy checks for any abnormalities such as a thickened lining of the womb called hyperplasia, polyps which are soft growths within the lining or fibroids which are hard growths that can be located inside the uterine cavity.
A hysteroscopy examination will help us investigate why you may be experiencing:
- Heavy periods
- Irregular bleeding whilst on the Hormonal Replacement Therapy known as HRT
- Breakthrough bleeding whilst on the oral contraceptive pill
- Unusual bleeding or bleeding in between your periods
- Post-menopausal bleeding
- Difficulty in getting pregnant
- Recurrent miscarriages
- Dividing a uterine bridge known as a septum
- Dividing adhesions within the uterine cavity known Asherman’s syndrome
This is usually a day case procedure which is performed by Mr Disu using a tiny 2.9mm betocchi hysteroscope to a biopsy from the lining of the womb (endometrial biopsy) to remove polyps, fibroids.
One in fifteen referrals are for a missing coil or a mispositioned coil.
Mr Disu uses the miniature hysteroscope for removal of any displaced intrauterine devices such as the copper coil or Mirena intrauterine system. This can be done whilst you are awake or preferably whilst you are asleep. It is a day case procedure and is covered with antibiotics to prevent an infection.
This involves using a loop bipolar energy device which is 4mm thick to shave off polyps or fibroids. It is usually performed whilst you are asleep.
The tissue is sent for testing in the laboratory and results are usually ready within 48hours to 72hours depending on the day of the surgery within the week.
It is important that you are not pregnant at the time of the procedure. A sample of urine may be requested for a urine pregnancy test on arrival.
If you are sexually active, please use contraception from your last period until the appointment.
Include abdominal discomfort, pain, feeling sick, fainting, mild bleeding, infection risk is low at 1/400 procedures and damage to the wall of the uterus is also low at 1/1000procedures. An overnight stay for observation may be offered if this rare event were to occur.
The examination may fail in 4% (4 in 100) of women most commonly due to difficulty passing the camera through the cervix. In such cases, Mr Disu may recommend that this procedure be performed under a general anaesthetic at a later date. Mr Disu also performs division of cervical adhesions whilst under general anaesthetic or using local anaesthetic using the miniature hysteroscopy.
An anaesthetist usually attends to your questions prior to procedure. This is to ensure that all medical problems are discussed prior to being put to sleep.
If your case is done under local anaesthetic, then Mr Disu will explain the procedure in detail and provide a leaflet prior to booking your procedure.
The examination is a safe established diagnostic procedure which is a national recommendation across the United Kingdom.
Laparoscopic myomectomy
Laparoscopic myomectomy is keyhole surgery to remove fibroids. Fibroids are usually benign growths of the womb that can affect the menstrual cycle causing heavy periods as well as bladder symptoms and bowel symptoms.
There are 7 types of fibroids based on location. Some are within the lining of the womb. These are called submucosal fibroids while others are within the muscles of the womb. These are called intramural. There are varying other types of fibroids that grow outwards from the womb named subserosal, serosal or pedunculated fibroids.
Laparoscopic myomectomy is a keyhole surgical procedure (also known as minimally invasive surgery) involving up to 4 small incisions (≈1cm) on the abdomen (tummy) under general anaesthesia to remove fibroids.
Surgical instruments are inserted through the incisions and the operation is carried out with the aid of an internal camera (the laparoscope). The fibroids are separated by making cuts into the uterus (womb) and then repairing the area that has been cut. The fibroids are then removed through one of the incisions using a device called a power morcellator. This can be done in a bag or without a bag depending on the type of fibroid.
The advantage of laparoscopic myomectomy is shorter hospital stay, usually one or two days in hospital and faster recovery time usually 2 weeks to 6 weeks. There is also less bleeding and less pain after the surgery compared to an open myomectomy. There is also less scarring of the skin as the incisions are paper cuts of 1cm or less. The cuts are closed with medical glue for aesthetics and to prevent infection.
- Post-operative pain and bloating
- Wound infection, delayed would healing or bruising
- Urinary infection or inability to pass urine (up to 10% particularly with anterior fibroids)
- Conversion to open myomectomy surgery (1:30)
- Excessive bleeding requiring blood transfusion (4-5:100)
- Injury to bowel, bladder, ureters (tubes connecting the kidneys to the bladder) or blood vessels (2:1000)
- Hernia at the site of incision
- Blood clots in leg or lung
- Pelvic infection or abscess
- Return to theatre because of delayed bleeding
- Adverse reaction to the anaesthetic
- Hysterectomy – removal of the womb due to bleeding (1 in 700 to 1in 1000)
Recurrence of symptoms such as heavy menstrual bleeding can occur in 4- 40% within 5 years in women under the age of 32. This is because fibroids can grow maximally in size between the ages of 32-38 years of age. The average age of my cohort of patient is about 42years.
Fertility – chances are improved after laparoscopic myomectomy. My first cohort of 35patients resulted in a pregnancy within 18months in 6 women who then required a caesarean section due to previous myomectomy surgery. The second cohort of 100 laparoscopic myomectomy patient had good pregnancy outcomes with 12 women above the age of 38yrs getting pregnant and having caesarean section delivery due to the size and site of the previous fibroids that were removed.
- You may feel bloated and have pain around the shoulders from the gas that is used to inflate your abdomen. This will settle over a few days as the gas is absorbed by the body. You will be given regular painkillers.
- Energy levels: It is common to feel tired in the first 1-2 weeks.
- Vaginal bleeding: You can expect some vaginal bleeding/discharge for 1-2 weeks. Use sanitary towels instead of tampons.
- Stitches: The stiches used to close the incisions will dissolve over 4-6 weeks. If there is a problem, make an appointment to see your Practice Nurse.
- Exercise: It is advisable to go for short walks. You may start cycling and swimming after 4 weeks.
- Sex: You can resume sex when you feel recovered from the operation.
- Work: You may return to work after 2 weeks.
- Follow-up: You will be given a clinic appointment approximately 6 weeks after the operation.
Laparoscopic treatment for endometriosis
Endometriosis is a disease in which endometrial glands in the lining of the womb are found to grow in areas outside the womb (uterus).
The most common place to find implants is in the peritoneal cavity (involving the ovary, cul-de-sac, uterosacral ligaments at the back of the womb, broad, round ligaments, fallopian tubes, colon, and appendix.
Endometriosis lesions have occasionally been found in the pleural cavity, liver, kidney, gluteal muscles, bladder, abdominal scars, and even in men.
There are three typical types of endometriotic lesions:
- Superficial peritoneal and ovarian implants
- 2) endometriomas (ovarian cysts that are lined with endometrioid mucosa)
- 3) deep infiltrating endometriosis (complex nodules comprised of endometriotic tissue, adipose tissue, and fibromuscular tissue) (2,3).
The site of the endometriosis lesions as well as the inflammatory response from these lesions are believed to be responsible for the symptoms and signs of endometriosis.
The most common theory is that of John Albert Sampson’s theory from 1921 of retrograde back flow menstruation, transplantation and implantation.
This theory alludes to shedding of endometrial debris through their fallopian tubes into the peritoneum during menstruation. There is evidence of the endometrial tissue been found in the fallopian tubes and peritoneal fluid of women due to gravity. It is also common in women with tilted wombs – Retroverted uterus.
About 1 in 20 women suffer from endometriosis worldwide. One million women are diagnosed with endometriosis which is equivalent to the number of new diabetes diagnosis.
Testing and triaging endometriosis can begin with a knowledge and awareness of the diagnosis which includes pelvic pain, painful periods, painful intercourse and heavy menstrual bleeding. Other symptoms include painful urine and painful bowel motion. There is also a close association with mood swings, anxiety, sleep disorders, depression and emotional state. These symptoms cause absenteeism at work and disturb everyday life.
A blood test called the carbohydrate antigen 125 may be used to triage if endometriosis is active or not. This test should be ideally carried out when the women are not menstruating.
Laparoscopy is the gold standard for detecting endometriosis. It involves a tiny paper cut incision in the belly button under general anaesthesia to look for the blue black endometriotic spots/nodules in the areas described above such as behind the ovaries, behind the womb and over the bladder area.
Ultrasound of the pelvis may also allude to advanced endometriosis of the ovary and bowel. Magnetic resonance imaging (MRI) is also good at detected deeply infiltrating endometriosis and smaller lesions on the bowel or pelvic walls.
Laparoscopy could be a day case procedure or may involve an overnight stay if endometriosis nodules have to be excised. Recovery usually takes 2 to 6 weeks.
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