Pelvic Complaints Overview
The pelvic complaints discussed in this section concern devices placed (or misplaced) in the vaginal area, such as pessaries or tampons, and vaginal discharge and lesions. Often when a patient has complaints in this region, they are vague and overlapping. Careful questioning is needed to determine the true nature of the complaint.
Far too many vulvar and vaginal infections are managed over the telephone. The reasons are patients often have symptoms they’ve had before and are self-diagnosing, providers have only so much time and many such complaints are dismissed as minor, and there are a host of available over-the-counter products worth trying. In reality, it is hard not to treat these complaints via telephone for the sake of convenience alone.
However, there are compelling reasons to delay such treatment. Serious infections, some of them communicable, can be missed. Patient symptoms may be exacerbated by inappropriate treatments. Superinfection with simple and common body bacteria may occur. It can be better to offer patients some comfort measures for relief until they can be seen and their conditions adequately diagnosed. Your clinic or office practice philosophy often dictates what direction you take.
The biggest challenge in this arena is not letting a potential sexually transmitted infection (STI) go undiagnosed and thus missing an opportunity for proper treatment at a critical time. It is important to determine patients who may be at greatest risk for STIs. This also is a good opportunity to educate them about the signs and symptoms of potential problems. A chart of STI presenting symptoms, incubation periods, usual course of the disease, and important facts and implications are included here.
It is important to remember that urinary symptoms and vulvovaginitis symptoms may overlap. Yeast infections can affect the urethra and bladder, causing the familiar triad of dysuria, urgency, and frequency. Patients also may mistake the discomfort of urine irritating a vulvar lesion as symptoms of abnormal urination.
Some tried and true remedies may keep patients comfortable until they can be adequately evaluated. Some suggestions of common home remedies are zinc oxide, oatmeal bath products, cold compresses, bags of frozen vegetables secured in an outer wrapper, and even vegetable shortening! You should discuss with the providers with whom you work what comfort measures will be suggested to patients until they can be seen.
Comfort measures we recommend in our clinic/office are:
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Also included in this section are protocols for evaluating patients who have had common outpatient procedures who may call with common related complaints. Detailed information to answer questions regarding Pap smears is also provided. (Note: Zika and other emerging diseases that may be transmitted sexually are not included yet in the STI chart.) Information on these diseases may be found in Chapter 5, Table 5-1: Exposure to Selected Communicable Diseases in Pregnancy.
Abnormal Cervical Pap Smear
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STEP A: Unsatisfactory Smear
There are multiple reasons for unsatisfactory smears. Because the Pap test requires a sample of cervical squamous and endocervical cells, anything that reduces the quality of that sample, such as blood, infection, recent intercourse, or vaginal medication, may contribute to an unsatisfactory smear. Poor sampling technique on the part of the clinician and lab error can also produce an unsatisfactory result.
A Pap smear that is “unsatisfactory for evaluation” must be repeated under optimal sampling conditions as described above as soon as those conditions can be met.
STEP B: Epithelial Cell Abnormalities
This is an abnormal Pap smear. All abnormal Pap smears require follow-up with further testing. The abnormality should be further defined as one of the classifications in the following steps.
STEP C: ASCUS Pap Smear
An ASCUS test is considered a “borderline” abnormal test. This means that abnormal cells were seen on the smear, but they did not meet the criteria for dysplasia (precancerous cells). A DNA test for high-risk HPV may be ordered automatically (“reflex” test) at the time the pathologist determines the Pap to be ASCUS. It may also be ordered on request. You should know which of the labs that your office uses does DNA testing for high-risk HPV. High-risk types of HPV are associated with most cases of cervical cancer. Thus the presence of high-risk HPV raises the suspicion for dysplasia. Some practices may elect not to do HPV testing, in which case they usually order a repeat Pap after 1 year.
STEP D: ASCUS, Negative HPV
The Pap smear may be repeated in 1 year (normal interval).
STEP E: ASCUS/Positive HPV, LGSIL, or Higher*
STEP F: AGCUS Pap Smear
All reports with a reading of glandular cell abnormalities require further diagnostic testing. This may include colposcopy and endometrial biopsy (EMB; see Endometrial Biopsy protocol).
The ordering clinician will determine the course of action.
STEP G: Other Comments on Pap Smear
Some Pap reports may contain comments on the adequacy of the specimen, lack of endocervical cells, atrophic pattern, etc. How these comments are handled needs to be decided upon with your providers and may need to be individualized based on the patient’s health and Pap history.
» Patient Education
Take the opportunity to provide general information about the Pap smear screening test for cervical cancer. Advise that the Pap smear is only a screening test for cervical cancer. The test evaluates skin cells obtained from the uterine cervix. An abnormal test does not mean that the patient has cancer. Rather, it serves to narrow the number of women who require additional, potentially more invasive tests and/or treatment. Cervical cancer is not symptomatic until it is advanced. The purpose of the Pap smear is to detect asymptomatic premalignant and malignant lesions early.
Acquiring a good specimen is key to a meaningful Pap smear. The test should be scheduled at the midcycle when possible, and the patient should be instructed not to put anything in her vagina for 24 to 48 hours before the test (no tampons, douching, creams, gels, or intercourse).
The conventional Pap smear does not diagnose vaginal or cervical infections. However, the newer generation of Pap smears (ThinPrep, SurePap, etc.) can be used to diagnose chlamydia trachomatis (CT) and gonococcal (GC) infections. If the patient thinks she may have vaginitis, the Pap smear should be postponed, the infection treated, and the Pap should be rescheduled until symptoms have subsided and the vagina is clear of any medications.
The fear of potential cancer may make some patients unable to adequately take in the information you are providing. Make sure you stress that the Pap smear is only a screening test and further testing is needed for a diagnosis. Provide ample time for questions and make sure the patient knows how to reach you should more questions arise.
Every office/clinic should have a system for documenting follow-up for abnormal Pap smears and for tracking all Pap smears performed.
Colposcopy
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STEP A: Colposcopy for Diagnosis of Cervical Dysplasia
Cervical colposcopy is a diagnostic test for cervical cancer. It is the test that follows up an abnormal Pap smear. The purpose of colposcopy is to determine whether premalignant or malignant cells are present on the cervix. Cervical dysplasia (precancerous cells) cannot be detected by the naked eye. During colposcopy, the trained clinician (colposcopist) views the cervix and vagina under magnification with a binocular lens and filtered light (the colposcope). A dilute vinegar solution (acetic acid) is placed on the cervix and helps to highlight skin changes on the cervix. This allows the colposcopist to discern normal from abnormal tissue. Abnormal-appearing tissue can be sampled by punch biopsy. Biopsy provides a small sample of tissue for further laboratory examination to determine whether it is normal or abnormal and, if abnormal, how deeply it extends into the layers of tissue. An additional biopsy, called endocervical curettage (ECC), samples tissue from the inner cervical lining, an area that the clinician cannot visualize.
Precolposcopy instructions:
The client should be instructed to schedule her colposcopy when she is not menstruating. COLPOSCOPY CANNOT BE PERFORMED IF THE PATIENT IS MENSTRUATING. Menstruating clients must be rescheduled. The procedure takes about
15 minutes and is performed in the office. The patient is placed in the lithotomy position (the same position used for Pap smears). The patient should expect some discomfort or cramping during and shortly after biopsies are obtained. If the colposcopist ordered any preprocedure medications (such as ibuprofen), the client should take it half hour before the colposcopy.
15 minutes and is performed in the office. The patient is placed in the lithotomy position (the same position used for Pap smears). The patient should expect some discomfort or cramping during and shortly after biopsies are obtained. If the colposcopist ordered any preprocedure medications (such as ibuprofen), the client should take it half hour before the colposcopy.
Postcolposcopy instructions:
You may return to normal activities after colposcopy.
Expect some bloody, brownish, or “coffee-grounds” discharge for several days.
Do not insert anything vaginally for 5 to 7 days.
Results (pathology) will be available in 1 to 2 weeks. The colposcopist’s impression plus the biopsy results determine colposcopy follow-up (observation via Pap/colposcopy versus treatment).
Call the office if there is heavy bleeding (like a period), fever, or purulent discharge.
STEP B: Vulvar Colposcopy
Vulvar colposcopy is undertaken for further evaluation of visible external genital lesions. Speculum insertion is not required. The external genitalia are examined under magnification with the colposcope. Abnormal-appearing skin may be biopsied. Local anesthesia may be utilized. The procedure can be scheduled at any time during the patient’s cycle. Post procedure, the patient can expect some discomfort and oozing of serosanguineous (pinkish tinged, watery) fluid at the biopsy site. Silver nitrate, applied to the biopsy site to control bleeding, will leave a black stain on the skin that will clear when healed.
It may be wise to advise the patient to schedule vulvar colposcopy and possible biopsy when she anticipates 24 to 48 hours of limited to light activity. She should be advised to avoid wearing tight-fitting clothing and avoid intercourse or strenuous exercise during this initial period.
Instruct her to call if any frank bleeding occurs that does not stop with pressure to the area. She should apply pressure with a sterile gauze pad for 2 to 5 minutes.
» Patient Education
Not every colposcopy ends in biopsy! Patients need to understand that the colposcopy may provide reassurance that the Pap smear was “overcalled.”
The patient needs to have a plan for receiving her results and a clear understanding of what the plan will be for follow-up once the results are received.
The patient may need support while anxiously awaiting these results. Having realistic expectations about when the results will be available may help.
Conization (Cold Knife Conization, Loop Electrosurgical Excision Procedure; Large Loop Excision of the Transformation Zone)
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STEP A: Provide General Information About the Conization Procedure
A conization is a procedure in which a cone-shaped section of the cervix, including all of the T zone (when possible), is removed. Conization can be done using a scalpel, laser, or loop electrosurgical instrument. The tissue sample is obtained to allow a pathologist to determine the degree of cervical abnormality and helps to inform the gynecologist as to the proper patient management approach. The conization may be performed in an outpatient operative setting or in some cases an office setting. Patients are typically sedated for the procedure. Conization is usually not performed on a patient who is pregnant, unless there is a strong suspicion of invasive cervical cancer.
STEP B: Post Conization
After the conization, the patient may experience cramping. She may note bleeding similar to a menstrual period or a small amount of bleeding or spotting. Heavy bleeding warrants same-day evaluation by a provider. If bleeding is extremely heavy, advise patient to call 911. A purulent discharge or fever should be reported to the health care provider, and the patient should be offered a same-day appointment.
» Patient Education
Diazepam (Valium) or a similar tranquilizer may be prescribed for patients who are unusually nervous. Providers may ask the patient to have someone accompany them in the event they feel unsteady or unable to transport themselves after the procedure.
Some providers may advise the patient to take a nonsteroidal anti-inflammatory drug (NSAID) (such as Advil [ibuprofen], Motrin [ibuprofen], or Aleve [naproxen sodium]) for pain relief following the conization. Others may prescribe an analgesic.
Patients are typically instructed to insert nothing vaginally and to refrain from intercourse for 2 to 4 weeks following a conization.
It is common for women who have had a conization to experiencing spotting, or bleeding less than a menstrual period 1 to 2 weeks, following the procedure as sutures inserted at the time of the conization dissolve.
The results of the conization are typically available within 1 to 2 weeks. The provider may either contact the patient over the telephone regarding the results of this test or schedule a follow-up visit to discuss the results and any further tests or treatments that may be required.
Repeat cytology (e.g., a Pap smear) is usually done 3 to 4 months after the conization to reevaluate cervical status.
Cryosurgery
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STEP A: Vaginal Discharge
Patients often experience a watery, copious, gray, or brown discharge after cryosurgery. The thick, mucus-laden discharge after cryosurgery occurs as frozen cervical cells slough.
If the discharge is accompanied by a foul odor, instruct the patient to take her temperature. If she has an oral temperature greater than 100° F or the vaginal discharge smells foul or fishy, schedule a same-day appointment to evaluate the patient for infection.
Complete questions 2 to 4 for a thorough assessment.
STEP B: Fever
Temperature rarely exceeds 100° F after cryosurgery.
An oral temperature greater than 100° F may indicate an infection. The patient should receive a same-day appointment.
Complete questions 3 and 4.
STEP C: Bleeding
More than minimal bleeding is extremely rare after cryosurgery.
Confirm that the bleeding is not the patient’s normal menstrual period.
If the bleeding soils more than one pad in 2 hours or is accompanied by heavy clots, the patient should be seen in the office immediately.
Continue to Question 4.
STEP D: Vaginal Odor
As frozen vaginal cells slough, the patient may notice a fleshy vaginal odor.
If the patient reports a foul or fishy odor or has a temperature greater than 100° F, schedule a same-day appointment to determine if she has an infection.
» Patient Education
Cryosurgery is not done if the patient is pregnant or menstruating.
Advise the patient of the following:
Do not use tampons for at least 2 weeks.
Avoid intercourse for 2 weeks.
Watery discharge without odor is normal for up to 4 weeks.
Endometrial Ablation
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STEP A: Overview of Endometrial Ablation
The lining of the uterus is known as the endometrium. Each month, the endometrium is shed during a woman’s menstrual period. Some women, particularly those who are approaching menopause, may experience heavy, frequent, or lengthy menstrual periods. These types of menstrual periods can be managed with medications, but some women may not be able to take such medications or would like to control their menses by a procedure known as endometrial ablation.
Endometrial ablation uses sound waves, electrical, laser, or thermal (heat) energy to destroy a thin layer of the endometrium, resulting in either cessation of menstrual bleeding, much lighter menstrual flow, or spotting. Because endometrial ablation destroys a layer of the endometrium, it should not be done on women who would like to have more children. Although this procedure often results in infertility,
women who have had an ablation should use backup contraception until hormone and other tests indicate they are in menopause.
women who have had an ablation should use backup contraception until hormone and other tests indicate they are in menopause.
Endometrial ablation takes very little time and is usually done either in an outpatient surgicenter or an office. Patients typically receive mild sedation for the procedure, so they will need to be accompanied by someone who can drive them home. After the procedure, some women experience mild menstrual-like cramps for a day or two, a watery blood-tinged discharge, mild nausea, and increased urination for about 24 hours. Women typically return to their normal activities the day after the procedure.
Potential risks associated with ablation include blood loss, infection, fluid retention, uterine perforation, or reactions to any pain medications that are administered. The rate of such risks is extremely low.
STEP B: Preparing for an Endometrial Ablation
Before the ablation, the provider may order a complete blood cell (CBC) count to rule out anemia or infection. An ultrasound is usually ordered because the presence of a fibroid (benign growth in or on the uterus) or other uterine abnormality may help the gynecologist determine which type of ablation approach is best, or if the patient is not an appropriate candidate for an ablation. If the provider suspects that the lining of the uterus is out of phase or wants to rule out a problem with the lining of the uterus, an endometrial biopsy (EMB) may be performed.
Ablation is usually avoided during menstruation. Ablation is usually a same-day surgery procedure and analgesia/anesthesia is required. Consequently, the patient should have no food or liquids for 8 hours prior to the ablation or per the protocol where the procedure will be performed.
No incisions are required for an ablation, and the patient can be expected to be discharged to home about 2 hours after the procedure is completed. Because patients receive sedation, they should be accompanied by someone who can drive them home. The majority of patients return to normal activities the day after the ablation.
STEP C: What to Expect Following an Endometrial Ablation
Common minor side effects associated with ablation include:
mild, menstrual-like cramps for 1 to 2 days;
increased urination for 24 hours after the procedure;
a small amount of watery vaginal discharge (the discharge may be blood-tinged, and this discharge can last for several weeks); and
nausea.
Douching, intercourse, or use of tampons is usually avoided for 2 weeks. Also, a method of contraception (such as condoms) is recommended.
If the patient reports heavy vaginal bleeding (more than a menstrual period) or shortness of breath, a provider should be contacted immediately. Women who complain of increased swelling, unusual vaginal odor, or fever should receive a same-day appointment.
Endometrial Biopsy (EMB)
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