Obs&Gynae -Obstetrics and Gynaecology Update Blog

Οbs and Gynae είναι η cool συντομογραφία του Οbstetrician and Gynaecologist, τουτέστιν Μαιευτήρα-Γυναικολόγου. Το blog αυτό λοιπόν είναι αφιερωμένο στην ενημέρωση πάνω στη μαιευτική και γυναικολογία και στην απάντηση σχετικών ερωτήσεων. Obs and Gynae, abbreviation for Obstetrics and Gynaecology, in British hospitals. This is a blog dedicated to updated information and links to academic institutions, all that in simple terms and lay language. Also available at www.gynecologists.gr

06/07/2013

Bartholin's cyst- a rather commmon cause of vulvar discomfort

Near the introitus (that is, the opening of the vagina, but we need to talk in proper medical terms, this is not a cosmopolitan blog…), there are two glands, one on each side, just behind the labia. They are called Bartholin glands, named after a Danish anatomist, Caspar Bartholin in the 17^th century.

They are small, you cannot palpate them and they produce a thick secretion, in order to lubricate and protect the lining of the vagina. They were thought to be related to lubrication during sexual arousal but, alas, their contribution is minimal. The glandular fluid enters the vaginal epithelium through a narrow tube, the duct.

Occasionally, for unknown reasons, the duct will get blocked and the sticky fluid will accumulate within the gland and the gland will become swollen. This is a bartholin cyst, and it affects 2% of women, mostly aged between 20 and 30. It may be asymptomatic, with just a local swelling and minor discomfort. If the cyst becomes infected, it then becomes an abscess, very tender indeed, the patient may find it difficult to walk and it needs urgent treatment.

It is not related to sexual intercourse and don’t blame your partner for transmitting the infection- there are many other reasons to blame your partner but not Bartholin issues.

It is equally not related to poor hygiene, tight underwear, sweating, swimming, the duct somehow decides to block itself and there is nothing you can do to prevent it from happening- frequent question when someone already suffered from one gland and wishes to avoid trouble from the other side in the future.

We tend to give a short course of antibiotic when a cyst appear, to prevent infection and this may delay the process but eventually things will get worse. The cyst will need to be drained and ideally a new duct should be surgically created. This procedure is called marsupialisation ( from Latin marsūpium, from Ancient Greek μαρσίππιον (marsippion), diminutive of μάρσιπος (marsipos, “pouch”))- yes, blame the Greeks for everything… This is a minor operation, it needs anaesthetic and it involves exteriorisation of the gland internal to the vaginal lining so that the fluid will readily be expelled in the future.

It is therefore a rather nasty situation but it is benign and will not affect your future sex life or fertility. Having said that, in older women (above the age of 40) we have the extremely rare bartholin gland cancer, so all labial swellings should be reviewed by a gynaecologist.

To summarise, when in pain, see your doctor and blame Caspar Bartholin …

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HPV and Genital Warts

Human papilloma virus (HPV) is the most common sexually transmitted infection and it is likely that most of us have had HPV at some time in our lives — although we may not have known it. So what is HPV, how can it be prevented and treated, and what does papilloma mean anyway?

Papilloma means a growth or wart, which is why HPV is also known as the 'wart virus'. In practical terms, however, only about 10% of people with HPV develop warts. The vast majority of people with HPV don't, and are therefore unlikely to know that they are infected or that they may be passing the virus to their sexual partner(s).
Young sexually active people are at greatest risk of getting genital HPV, with the highest rate of infection in those between the ages of 20 and 24. Recent research suggests that many young women may become infected with the virus during their first sexual experience, and the risk of infection increases with the number of sexual partners. HPV prevalence seems to decrease with age.

What is HPV?
There are thought to be more than 100 types of human papilloma virus that can infect the body. Some strains lead to common warts on people's hands and feet, but these are different from genital warts and cross-infection is extremely rare. About 30 types of HPV affect the genital area. Some types cause genital warts, others cause changes in cervical cells that may lead to cervical cancer, but most HPV infections cause no symptoms at all and go away on their own.

How is the virus spread?
Genital HPV is highly infectious, particularly when warts are present, and is spread mainly through direct skin-to-skin contact with the infected area. Genital HPV is passed on during sexual contact, including vaginal and anal sex, oral sex and, while less risky, non-penetrative sex play. It is also possible for sex toys to carry an infection from one person to another. In rare cases, HPV may be spread without direct sexual contact. It may be possible, for example, to pick up the virus if you use a towel to wipe your genitals after it has been used by someone who has HPV or genital warts.

How do I know if I have HPV?
Genital warts are the only visible sign of HPV infection, but they may not appear for weeks, months or even years after infection occurs, if they appear at all. Women are more likely than men to develop warts, and they can grow on the lips of the vulva, around the clitoris, inside the vagina, around the urethra, on the cervix, on the area between the vagina and the anus (perianal region), and in and around the anus itself. In men, warts tend to develop on the tip and shaft of the penis, on the scrotum, as well as in and around the anus. Although rare, genital warts may develop in a person's mouth or throat if infected through oral sex.
Warts may appear as small red or white bumps, they may grow alone or in cauliflower-like clusters, or they may be flat and barely visible.
Genital warts are generally not painful, but may be itchy or uncomfortable. You may not realise you have warts, particularly if they are small, inside the vagina or on your cervix.

How is HPV diagnosed?

HPV is usually diagnosed based on the presence of genital warts. If there are no obvious warts, but infection is suspected (because a partner has warts, for example), the doctor may apply a solution that turns warts white, making very small or flat warts more visible.
An abnormal smear result may be a sign that you have been exposed to HPV, but not all cervical smears can detect current HPV infection. If your smear result suggests HPV might be present, you may be scheduled for another smear, or for a colposcopy. During a colposcopy, we look at your cervix through a microscope (the colposcope) for signs of HPV and we may take a sample (biopsy) of cervical tissue for further investigations. If you don't have visible genital warts and your smear result doesn't show signs of HPV, there is currently no other way of knowing whether or not you have the virus.
HPV — prevention and new developments
Unfortunately there is no entirely effective way of preventing HPV aside from not having sex or sexual contact. Using condoms may help to prevent HPV, but because they do not cover the entire genital area, and are often put on after sexual contact has begun, the virus can still be passed on, even during 'safe sex'.
Using a condom for 3 to 6 months following treatment for warts may help prevent reinfection for you and your partner, and is usually recommended as part of a treatment programme. Risk factors, which, if avoided, may reduce your risk of getting HPV include: smoking, having multiple sexual partners and exposure to other sexually transmitted infections.
Are there any new developments in HPV prevention, diagnosis and treatment?
Researchers are working to develop two types of HPV vaccines: one which would offer protection to people who have not been infected, and another which could be used to help treat HPV and cervical cancer in people who have been infected. In the UK, ongoing pilot studies are investigating new HPV tests that diagnose the virus when a smear test is done.
Fortunately, most HPV infections go away on their own within six months to two years without causing any complications or harmful long-term effects. For people with genital warts, the psychological and emotional impact of having warts is often the worst part of HPV. Some infections, however, may be linked to other problems, including recurring warts, other sexually transmitted infections (STIs) and cervical cancer.
Abnormal smear results and cervical cancer
Some types of HPV can lead to abnormal cell changes on a woman's cervix. These changes are known as CIN (cervical intra-epithelial neoplasia), which means 'new changes in the outer layer of the cervix'. In many cases, abnormal cells revert back to normal without treatment, but sometimes they do not. If left untreated, these cells may develop into cervical cancer, but it usually takes 10 to 20 years for this to happen. Fortunately, the progression to cervical cancer can be easily prevented if abnormal changes are found and treated early. Smear tests are currently the only way to detect abnormal cell changes, and are therefore the best way to protect yourself from cervical cancer. If you have been diagnosed with HPV, you may be scheduled for more frequent cervical screening — every 6 to12 months — to keep an eye on cervical cell changes. If the cells do not return to normal, or changes are severe, we will need to consider treatment options to remove the abnormal cells.
If you have visible genital warts, you probably do not have a type of HPV that is linked to cancer.
The two most common strains of HPV linked to cervical cancer are HPV 16 and 18, but most women with HPV, including those infected with type 16 or 18, do not develop cancer. Other strains of the HPV virus have also been linked to cervical and other more rare cancers, such as vulval and anal cancer.
What if I'm pregnant and have warts?
Warts tend to grow rapidly during pregnancy and may become numerous and large. This may be due to a weakened immune system, but there is some evidence to suggest that HPV is influenced by progesterone, which is high during pregnancy. In most cases warts will not interfere with pregnancy or birth but if the warts are very large, they may need to be removed.
The safest treatments during pregnancy are cryotherapy and surgery. In severe cases, if large warts cannot be removed, it may be necessary to have a caesarean section.
Although rare, HPV may be passed on to a baby through warts in the birth canal. This is not a serious condition, but it is possible for the baby to develop warts in the throat if exposed to the wart virus. Known as laryngeal papillomatosis, this can cause breathing problems in the baby, but the risk of this happening is extremely low and therefore is not, on its own, a reason to perform a caesarean section.