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Tests for Gynecologic Disorders

by David H. Barad, MD, MS

Sometimes doctors recommend screening tests ( Tools of Prevention : Screening), which are tests that are done to look for disorders in people who have no symptoms. Women with gynecologic symptoms sometimes need to have diagnostic procedures done.

Screening Tests

Two important screening tests for women are cervical cell (cytology) testing, such as the Papanicolaou (Pap) test, to check for cancer of the cervix (the lower part of the uterus) and mammography to check for breast cancer (see Breast Disorders:Mammography). Women at risk of sexually transmitted diseases should be screened for these diseases. Other screening tests are done in pregnant women (see Medical Care During Pregnancy).

Screening for Cervical Cancer

Cervical cytology testing (such as the Pap test) involves collecting a sample of cells from the cervix and examining them under a microscope. There are two types of cervical cytology tests: the conventional test and the liquid-based test. Doctors collect the sample by inserting a speculum into the vagina to spread the walls of the vagina apart and using a plastic spatula (similar to a tongue depressor) to remove some cells from the surface and opening of the cervix. Then, a small bristle brush is inserted into the passageway through the cervix (cervical canal) to obtain cells from the wall of the canal. The samples are sent to a laboratory, where they are examined under a microscope for abnormal cells, which may indicate precancerous changes or, rarely, cervical cancer. Usually, the Pap test feels scratchy or crampy, but it is not painful and takes only a few seconds.

Pap tests identify 80 to 85% of cervical cancers, even very early-stage cancer. They can also detect changes in cervical cells that can lead to cancer (precancerous changes). These changes, called cervical intraepithelial neoplasia (CIN), can be treated, thus helping prevent cancer.

Pap tests are most accurate if the woman is not having her period and does not douche or use vaginal creams for at least 24 hours before the test. Experts now recommend that the first Pap test be done after a women reaches the age of 21 years. How often the test is needed depends mainly on the woman’s age and the results of previous Pap tests:

  • From age 21 to 30: Testing is usually done every 3 years

  • After age 30: Testing is done every 3 years if only a Pap test is done or every 5 years if a Pap test and a test for human papillomavirus (HPV) are done. However, women with a high risk of cervical cancer need to be tested more frequently. Such women include those who have an HIV (human immunodeficiency virus) infection, who have a weakened immune system (which may result from taking a drug or having a disorder that suppresses the immune system), or who have had abnormal Pap test results.

  • After age 65 or 70: Testing is no longer needed if test results have been normal for at least 3 years in a row and no result has been abnormal in the last 10 years. Pap tests should be resumed if the woman has a new sex partner or should be continued if she has several sex partners.

Women who have had their uterus completely removed (total hysterectomy) and have not had any abnormal Pap test results do not need Pap tests.

Screening for Sexually Transmitted Diseases

Women at risk of sexually transmitted diseases should be screened yearly for these diseases, even if they have no symptoms. High-risk women include the following:

  • Sexually active women aged 25 and younger

  • Women who are just beginning sexual activity

  • Women who have several sex partners

  • Women whose partner has had several sex partners

  • Women who have had a sexually transmitted disease

  • Women who do not consistently use a barrier contraceptive (such as a condom) and are not in a mutually monogamous relationship or are unsure whether the relationship is mutually monogamous

  • Pregnant women

  • Women who have a vaginal discharge

For most sexually transmitted diseases, the doctor uses a swab to obtain a small amount of cervical discharge from the cervix. The sample is sent to a laboratory for analysis. Women who think they may have one of these diseases can request screening. Testing for gonorrhea and chlamydial infection can also be done using a urine specimen or a sample from inside the vagina obtained by the woman with a swab.

A doctor may consider screening women for HPV if they are 30 years old or older, if a Pap test detected abnormalities that may result from HPV infection, or if the results were not clear. HPV can cause genital warts or cervical cancer. A sample of vaginal discharge, obtained with a swab, is used for this test. Normal results of an HPV test indicate that cervical cancer and precancerous conditions are highly unlikely. For women at high risk of HPV infection, the HPV test can be done at the same time as a Pap test. If results of a Pap test and an HPV test are normal in women older than 30, neither test needs to be repeated for at least 3 years.

Diagnostic Procedures

Occasionally, more extensive diagnostic procedures are needed.

Biopsy

A biopsy consists of removing a small sample of tissue for examination under a microscope. Biopsy of the vulva, vagina, cervix, or lining of the uterus can be done.

Cervix or vagina

A cervical biopsy is done when a condition likely to eventually lead to cancer (precancerous condition) or cancer is suspected, usually because a Pap test result was abnormal. A biopsy of the cervix or vagina is usually done during colposcopy. During colposcopy, doctors can identify the area that looks most abnormal and take tissue samples from it. Usually, biopsy of the cervix or vagina does not require an anesthetic, although this procedure typically feels like a sharp pinch or a cramp. Taking a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen, 20 minutes before the procedure may help relieve any discomfort during the procedure.

Vulva

A biopsy of the vulva (the area around the opening of the vagina) can usually be done in the doctor's office and requires use of a local anesthetic.

Uterus

For biopsy of the lining of the uterus (endometrial biopsy), a speculum is used to spread the walls of the vagina, and a small metal or plastic tube is inserted through the cervix into the uterus. The tube is used to suction tissue from the uterine lining. This procedure is usually done to determine the cause of abnormal vaginal bleeding. Also, infertility specialists use this procedure to determine whether ovulation is occurring normally and whether the uterus is ready for implantation of embryos. An endometrial biopsy can be done in a doctor's office and usually does not require an anesthetic. Typically, it feels like strong menstrual cramps. Taking an NSAID, such as ibuprofen, 20 minutes before the procedure may help relieve discomfort during the procedure.

Colposcopy

Colposcopy is often done if results of a Papanicolaou (Pap) test are abnormal. For colposcopy, a speculum is used to spread the walls of the vagina and a binocular magnifying lens (similar to that of a microscope) is used to inspect the cervix for signs of cancer. Often, a sample of tissue is removed for examination under a microscope (biopsy). Colposcopy alone (without biopsy) is painless and thus requires no anesthetic. The biopsy procedure is typically described as causing a crampy sensation and also does not require an anesthetic. The procedure usually takes 10 to 15 minutes.

Endocervical Curettage

Endocervical curettage consists of inserting a small, sharp, scoop-shaped instrument (curet) into the passageway through the cervix (cervical canal) to obtain tissue. The curet is used to scrape a small amount of tissue from high inside the cervical canal. A cervical biopsy (to remove a smaller piece of tissue from the surface of the cervix) is typically done at the same time. The tissue samples are examined under a microscope by a pathologist.

Endocervical curettage is done when endometrial or cervical cancer is suspected or needs to be ruled out. Usually, it is done during colposcopy and does not require an anesthetic.

Dilation and Curettage

D and C

After the speculum is in place, metal rods (not shown) are used to stretch open the cervix so that the curet can be inserted into the uterus. The curet is used to remove tissue from the lining of the uterus.

For dilation and curettage (D and C), a speculum is used to spread the walls of the vagina. Then, metal rods are used to stretch open (dilate) the cervix so that a small, sharp, scoop-shaped instrument (curet) can be inserted to remove tissue from the lining of the uterus.

This procedure may be used to treat women who have had an incomplete (partial) miscarriage. D and C is sometimes used to identify abnormalities of the uterine lining when biopsy results are inconclusive, but it is no longer commonly used for this purpose because biopsies usually provide as much information and can be done in the doctor’s office. D and C is often done in a hospital. Conscious sedation (when people can breathe on their own and respond to directions but do not feel pain) or a general anesthetic may be used. However, most women do not have to stay overnight in the hospital.

Hysterosalpingography

For hysterosalpingography, x-rays are taken after a radiopaque dye (which can be seen on x-rays) is injected through the cervix to outline the interior of the uterus and fallopian tubes.

The procedure is often used to help determine the cause of infertility or to confirm that a sterilization procedure to block the tubes is successful. The procedure is done in a place where x-rays can be taken, such as a hospital or the radiology suite of a doctor's office. Hysterosalpingography usually causes discomfort, such as cramps. Taking an NSAID, such as ibuprofen, 20 minutes before the procedure may help relieve discomfort.

Hysteroscopy

To view the interior of the uterus, doctors can insert a thin viewing tube (hysteroscope) through the vagina and cervix into the uterus. The tube is about 1/4 inch in diameter and contains cables that transmit light. Instruments used for a biopsy, electrocautery (heat), or surgery may be threaded through the tube. The site of abnormal bleeding or other abnormalities can usually be seen and can be sampled for a biopsy, sealed off using heat, or removed. This procedure may be done in a doctor's office, or it may be done in a hospital with a general anesthetic at the same time as dilation and curettage.

Laparoscopy

To directly examine the uterus, fallopian tubes, or ovaries, doctors use a viewing tube called a laparoscope. The laparoscope is attached to a thin cable containing flexible plastic or glass rods that transmit light. The laparoscope is inserted into the abdominal cavity through a small incision just below the navel. A probe is inserted through the vagina and into the uterus. The probe enables doctors to manipulate the organs for better viewing. Carbon dioxide is pumped through the laparoscope to inflate the abdomen, so that organs in the abdomen and pelvis can be seen clearly.

Often, laparoscopy is used to determine the cause of pelvic pain, infertility, and other gynecologic disorders. Instruments can be threaded through the laparoscope to do some surgical procedures, such as biopsies, sterilization procedures, and removal of an ectopic pregnancy in a fallopian tube. Additional incisions may be required if surgical procedures, such as removal of an ovarian cyst or the uterus (hysterectomy), are needed.

Laparoscopy is done in a hospital and requires an anesthetic, usually a general anesthetic. An overnight stay in the hospital is usually not required. Laparoscopy may cause abdominal pain, but normal activities can usually be resumed in 3 to 5 days, depending on the extent of the procedure that is done through the laparoscope.

Loop Electrical Excision Procedure

In a loop electrical excision procedure (LEEP), a thin wire loop that conducts an electrical current is used to remove a piece of tissue. Typically, this piece of tissue is larger than that obtained in a biopsy of the cervix.

This procedure may be done after an abnormal Pap test result to evaluate the abnormality more accurately or to remove the abnormal tissue. LEEP requires an anesthetic (often a local one), takes about 5 to 10 minutes, and can be done in a doctor's office. Afterward, women may feel mild to moderate discomfort and have a small amount of bleeding. Taking an NSAID, such as ibuprofen, 20 minutes before the procedure may help relieve discomfort during the procedure.

Sonohysterography

For sonohysterography, fluid is placed in the uterus through a thin tube (catheter) that is inserted through the vagina and then the cervix. Then ultrasonography is done. The fluid fills and stretches (distends) the uterus so that abnormalities inside the uterus, such as polyps or fibroids, can be more easily detected. The procedure is done in a doctor's office and may require a local anesthetic. Taking an NSAID, such as ibuprofen, 20 minutes before the procedure may help relieve discomfort.

Ultrasonography

Ultrasonography uses ultrasound waves, produced at a frequency too high to be heard. The ultrasound waves are emitted by a handheld device that is placed on the abdomen or inside the vagina. The waves reflect off internal structures, and the pattern of this reflection can be displayed on a monitor.

Ultrasonography can detect an ectopic pregnancy, tumors, cysts, and other abnormalities in the internal reproductive organs (ovaries, fallopian tubes, uterus, and vagina). It is commonly done during pregnancy to determine the condition and size of the fetus, to monitor the fetus, or to guide the placement of instruments during amniocentesis or chorionic villus sampling (see Procedures : Ultrasonography). Ultrasonography is painless and has no known risks.

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