Many women do not have routine gynaecological examinations. This may be because they lack money, because there is no clinic or hospital nearby that can do the exam, or simply because they do not know that such exams are important. If possible, women should have examinations and screening tests of their reproductive systems every 2-3 years even when they are feeling fine. This is especially true because many sexually transmitted diseases, cancers, and other gynaecological problems do not show symptoms until the illness is very far advanced. By then it may be difficult or even impossible to treat the problem effectively.
HISTORY: The first part of a routine gynaecological examination involves taking a careful history. Information should be gathered on the woman's age, gynaecological-obstetric history, medical-surgical history, family history, and social history. Specific problems, questions, and family planning choices are then discussed.
PHYSICAL EXAMINATION: A complete physical examination is then done, including an examination of the breasts and vagina. The vaginal exam usually has two parts. First the vagina and cervix are inspected with a speculum - an instrument placed inside the woman's vagina which, when opened, allows the health worker to check for any sores, bleeding, unusual fluids, or unhealthy tissue in the vagina or on the cervix. If the lab facilities are available, a Papanicolaou exam or Pap smear (a test for cervical cancer) may be done at this time. Swabs may be taken to test for infections like gonorrhoea and chlamydia. Genital warts, herpes blisters, and the sores caused by syphilis are other things that could be found during this part of the vaginal examination (see Chapter 18 on Sexually Transmitted Diseases).
The second part of the vaginal examination is done by placing one hand on the woman's abdomen and two gloved fingers inside the vagina. The size and tenderness of the womb, cervix, and ovaries can then be felt between the two hands. A rectal examination may or may not be done, depending on symptoms.
Many women find this part of the physical examination uncomfortable and embarrassing. It will help them to relax if they are told what is being done, and why it is done. A cloth or drape placed over the abdomen and thighs may also help them feel more comfortable.
LABORATORY TESTING: If the health facility has the necessary equipment and supplies, laboratory testing may include blood tests for sexually transmitted diseases such as HIV and syphilis. It may also include a complete blood count to look for anaemia.
Any problems found during the history, physical examination, or laboratory testing should be followed up as necessary. If a family planning method has been chosen, the health worker reviews its use, side-effects, and danger signs (see Chapter 17 on Family Planning and Child Spacing).
In addition to regular visits to a health facility, women can also monitor their own health. Health education that teaches women how to care for themselves and how to recognise danger signs is critical, especially in places where access to good medical care is limited.
BREAST SELF-EXAMINATION: It is perfectly normal for women to have lumps in their breasts. These can change in size and shape at different points in the menstrual cycle. Sometimes - fortunately, quite rarely - a lump in the breast that does not go away and does not change in size can be a sign of breast cancer. Most cases of breast cancer can be discovered by women themselves. For this reason it is important that women learn how to examine their own breasts, and how to tell when there is something wrong.
Breast self-examination should be done once a month, about one week after menstruation stops. Before menstruating, the examination is more difficult because the breasts are often more tender and slightly swollen. Women who have already gone through menopause, or women who are pregnant, may choose any time of the month that is easy for them to remember.
During the first part of the examination, women look at their own breasts in a mirror, if one is available. They should look first with their arms down and then with their arms raised, to check for any differences between the two sides (see Figure 20.1). It is normal to have breasts that are unequal in size. Signs of an abnormality would include: dimpling or puckering in one area, one nipple turning in a different direction, swelling, enlarged veins in a non-pregnant woman, or sores.
The second part of breast self-examination requires lying down and gently pressing all parts of the breast tissue against the chest. It is best if the arm next to the breast being examined is raised and placed under the head (see Figure 20.2). The area under the armpit should also be examined. Any lump that is new or feels different from a previous examination should be inspected at a hospital that can do the necessary tests and, if necessary, surgery. In most African countries, this treatment is available at teaching hospitals, usually in the capital city. It is important to begin treatment as soon as possible.
Figure 20.1: Breast Self-Exam while Standing or Kneeling
A woman should examine her breasts once each month. The first part of the exam should be done by standing in front of a mirror if available, and looking at the breasts.
Figure 20.2: Breast Self-Exam while Lying Down
The second part of the monthly breast exam should be done lying down. The woman should press each part of the breast to check for lumps.
MENSTRUAL IRREGULARITIES: Contraceptive methods that contain hormones (like oral contraceptives, implants, injectables, and some lUDs) can cause changes in a woman's normal menstrual cycle. The changes may include some bleeding in between periods, prolonged bleeding, or much less bleeding than normal. Stress, sudden weight loss, or weight gain are other reasons that bleeding patterns may change. In addition, the following women might have irregular periods: young girls who have recently started menstruating, women starting menopause, and women who recently delivered a baby.
However, unusual bleeding in a woman who does not belong to one of these groups may indicate cancer, an infection, or hormonal problems. In this case the woman needs to be examined by a doctor. Unusual bleeding may include prolonged bleeding, frequent bleeding, or very reduced bleeding. It may or may not be accompanied by pain. Women who have already passed menopause (no bleeding for one year) and start bleeding again should go as soon as possible for evaluation at a hospital.
PELVIC PAIN: Pain in the pelvis or abdomen that is not the normal discomfort of ovulation or menstruation can be a sign of a problem. There are two types of pain that are a cause for worry: pain that occurs during sexual intercourse, and pain that is constant.
Physical causes of painful intercourse may include vaginal infections or infections of the pelvic organs, female genital mutilation, bladder infections, cancers, uterine prolapse, and poorly healed episiotomies. An examination by a midwife or doctor is usually necessary to determine what the cause is. Women who are going through menopause (see page 193) and women who are breast-feeding may also find intercourse uncomfortable. This can be caused by the lack of fluids in the vagina, which is normal for women during this period. Using creams or oils during intercourse may help with this problem.
Painful intercourse may also be due to emotional or psychological difficulties. Women who are forced to have sex against their will or in ways that are not pleasurable will often find the experience painful. Sexual intercourse is a very private and personal topic, and many women are reluctant to talk about it. If they do admit to having a problem, however, there are various things a health worker can do to try to help. If there is a physical cause, such as lack of fluids in the vagina, they can advise the woman to use cream or oil. They can also encourage the woman to try speaking more openly with her husband or sexual partner about her individual needs and preferences.
Women who are abused, psychologically or physically, should be helped to make realistic changes or, if possible, leave the relationship entirely. Because the subject of abuse is difficult to talk about, and because some degree of abuse is accepted in many cultures, many women find it easiest to describe their physical symptoms first. By asking open-ended questions about sexual relations in a non-judgmental, supportive way, health care providers can give women the opportunity to discuss problems more openly.
Constant pelvic pain is most often caused by infections. Other causes can include cysts, cancers, endometriosis (a disease in which the inner lining of the womb starts to grow on the other parts of the internal organs), or other diseases of the pelvic organs. Women experiencing such pain should go to a hospital for evaluation.
Box 20.1: Signs of Reproductive Tract Problems
There are various signs that could indicate a problem with the reproductive organs. These include:
· Prolonged bleeding from the vagina (more than ten days)
If a woman is using a contraceptive method that contains hormones (the pill, implants, injectables, or some IUDs), unusual bleeding is common, and is not a cause for worry.
OTHER SIGNS OF A PROBLEM INCLUDE:
· Pain during sexual intercourse
· Constant pain in the pelvis
URINARY TRACT INFECTIONS: Symptoms of urinary tract infections include pain when urinating, having to urinate frequently, and blood in the urine. Women with these symptoms should go to a clinic for treatment immediately, since infections in the bladder and lower urinary tract may spread quickly to the kidneys. Kidney infection is a much more dangerous and painful illness. Women with kidney infections often have high fever and chills, nausea, vomiting, and back pain. Permanent scarring or damage to the kidneys may occur if not treated promptly. Admission to a hospital for treatment is often necessary.
Urinary tract infections can be avoided with good personal hygiene, especially by cleaning from front to back after a bowel movement in order to avoid bringing any of the stool near the urinary opening. Other steps that can help avoid infections include drinking plenty of fluids, urinating often (especially just after having intercourse), and wearing cotton under-wear or clothing that allows the area to stay dry. Having sexual intercourse very frequently or vigorously may also contribute to urinary tract infections. If a woman using a diaphragm experiences frequent infections, she should have the size of the diaphragm carefully checked or try a different form of contraception.
MENOPAUSE: Most women go through menopause between the ages of 45 and 55. During this time, their menstrual cycles usually become irregular and eventually stop altogether (see Box 20.2). They may experience short periods of sweating or flushing, rapid beating of the heart, and sleep disturbances. These changes naturally occur as the hormonal balance changes and the ovaries stop releasing eggs.
In addition to physical changes, menopause is also a time of emotional change, as women come to the end of their childbearing years. This may mean assuming a new role in the family or the community. For some women this can be a difficult process, and they may need extra support and understanding from their family members. Menopause may also be accompanied by new feelings of freedom, energy, and increased sexual desires.
CANCERS OF THE WOMB: The womb, like other organs in the body, can be afflicted with cancer. The part of the womb known as the cervix is the most frequently affected. Generally this disease is only found in older women (over age 40-45), although it can occur in women who are in their thirties. Women who have had genital warts (see Chapter 18) are more likely to develop cervical cancer, although any woman can develop the disease.
The most common sign of cancer of the womb or cervix is irregular bleeding from the vagina. This bleeding may start after menopause, or it may occur after sexual intercourse. This bleeding is a sign that the disease has already started spreading, so a woman with this symptom should go immediately to a hospital for an examination and treatment.
The disease is difficult to treat once it has reached the cancerous stage. Only a few hospitals in Africa can provide the necessary treatment. This treatment can involve an operation to remove the cancer from the cervix, or radiation therapy. Sometimes the entire womb and cervix have to be removed. While the prospect is a frightening one, it may be necessary to save the woman's life.
Box 20.2: Evaluating Unusual Bleeding During Menopause
Menstrual periods normally become irregular as women start menopause. Women going through menopause should go to a health facility if:
· bleeding occurs more frequently than once every three weeks
· bleeding starts again after menstrual periods have stopped for a year or more
Cancer of the cervix can be detected much earlier by the special test called a Pap smear, which was described earlier in this chapter. In its early stages, the disease can be treated much more easily, if the facilities are available. However, few health facilities can do the test. Some Ministries of Health are starting programmes to test for the early signs of cancer of the cervix, especially in older women. If possible, any woman over the age of 30-35 should be encouraged to go to a hospital or other health facility that can do the Pap test, especially if she has had genital warts. It could save her life.
Summary: Other Reproductive Health Needs
Women can have other problems related to their reproductive organs besides STDs and complications of pregnancy. Knowing about these problems, and how to prevent or defect them, can help a woman to get proper care early.
MONITORING AND SELF-CARE
Gynaecological examination: This examination should be performed every 2-3 years if possible, even when the woman is feeling healthy. It involves taking a medical history, a complete physical examination (including the breasts and vagina), and laboratory tests.
OTHER REPRODUCTIVE HEALTH PROBLEMS
Menstrual irregularities: Menstrual changes such as irregular periods, prolonged periods, or no periods can occur if a woman is using certain family planning methods, or if she is sick. However, they can also be signs of a disease in the reproductive organs. A woman with menstrual irregularities should go for an examination.
Cancers of the womb: Cancer of the cervix is very serious and must be detected and attended to as soon as possible. Signs of the disease are bleeding from the vagina after sexual intercourse, or bleeding after menopause. In the early stages, the cancer can be detected by a test called the Pap smear.