Conservative Treatment in Different Gynaecological Conditions
Many gynaecological conditions can be treated conservatively as a first choice of treatment rather than opting for surgery. Many women are very apprehensive about surgical procedures and surgery is not completely free of complications. After appropriate diagnosis to exclude any serious diseases, a reputable gynaecologist should aim to avoid surgery if at all possible by offering conservative treatment to their patients in the first instance.
The conditions that pertain to conservative treatment are:
1. Heavy bleeding and painful periods.
This can be treated with medication like anti-inflammatory non-steroidal drugs. In most of the cases particularly young patients, these medications work quite well. If they do not work, one can consider an oral combined contraceptive pill of low strength. The other alternative would be to insert a Mirena coil which usually has a very good result.
2. Irregular periods.
These can be rectified by giving an optimal dose of combined oral contraceptive pill, especially in younger women. If this does not work, then one can give cyclical progestogens (without estrogen) in a small dose.
Irregular cycle in perimenopausal is common and can easily be treated with appropriate hormonal treatment. Prior commencing on hormonal treatment one must exclude any serious disease like cancer of the genital tract.
3. Polycystic Ovarian Disease.
This has already been discussed at great length. LINK Although the name is suggestive of cysts in the ovary, removal of these cyst are not the correct treatment for this condition. Treatment with lifestyle changes are encouraged, in the first instance. Medications like Metformin for example has been used over the last few years with extremely good results. In young patients with excessive hair growth, one should consider a particular type of oral contraceptive pill which contains anti-testosterones.
Newer drugs and other natural hormonal combination pills are available which can be considered in the above cases.
4. In selected cases of fibroids.
All fibroids do not require surgical intervention. Small fibroids can be treated conservatively. If they suffer from heavy bleeding a Mirena can work quite well and should be considered as a conservative treatment. Large fibroids in women approaching menopause without any symptoms other than an enlarged uterus can be left alone, but regular monitoring is needed to check on any sudden increase in size. If they are associated with heavy bleeding and the patient is very near menopause, this can be achieved by giving an injection called GnRH analogue to stop the ovaries functioning to produce further oestrogen. A gynaecologist should be very confident before giving this treatment, that the patient is definitely near menopause and other factors should be considered.
5. Prolapse of the vagina and uterus.
Not all cases of prolapse require an operation. Particularly in older women where operative risks are present due to other co-existing diseases surgery should be avoided. Prolapse can be treated conservatively by using different types of vaginal pessaries. The pessaries can hold the vaginal prolapse in place thus avoiding an operation. The pessaries should be regularly checked and replaced between 4 to 6 months. This must be carried out and monitored by a trained specialist. Sometimes in younger women with prolapse keen to have more pregnancies, they should be given pessary treatment until they have completed their family when an operation can be performed.
6. Request for sterilisation.
A fair number of women request permanent sterilisation as they feel they are unable to continue with the oral contraceptive pill or other methods which they are not happy with. Long acting reversible contraceptive (LARC) is available and should seriously be considered in place of sterilization. Sterilisation is a permanent method which is very difficult to reverse. All the pros and cons are always discussed in depth by Mrs Purkayastha before a decision is made and proceeding to a permanent method of sterilisation.
Mild to moderate endometriosis, particularly in young women can be treated conservatively prior to surgery. Oral contraceptive pills, Mirena and a small dose of progestogens can be given cyclically or continuously in order to control the symptoms of endometriosis. If the symptoms of endometriosis are very severe, then an operation like laparoscopic destruction of the endometrial tissues/cyst/ should be considered.
8. Mild abnormal smears in young women.
An abnormal smear and its implication with cervical cancer have already been discussed, however in young women with very mild abnormalities, they should be kept under observation rather than performing any treatment like a loop excision or laser etc. This is because an operation on the cervix may cause damage to the cervix for any future pregnancies. More over there is no certainty that treating mild abnormalities surgically will prevent further recurrence of the disease. It is therefore worth considering waiting 18 months to 2 years with a mild abnormal smear, rather than embarking on surgery as a first treatment.