Textbook of Obstetrics and Gynaecology

Women’s reproductive health is a major determinant for pregnancy outcomes and their risk of various non-communicable diseases in later life. Besides the consequences for a woman’s own health, it also has important health consequences for her offspring. Adverse maternal exposures during pregnancy may adversely affect foetal development, leading to permanent developmental adaptations which predispose offspring to an increased risk of non-communicable diseases in adulthood. Using this life course approach to women’s health, we need to identify and create opportunities to improve women’s health through their life course and the health of future generations both at a population level as well as in patient care by using a multidisciplinary approach from early life onwards.

The life course approach in obstetrics and gynaecology respects the continuum of a woman’s life. The continuum is a one-way direction, which already starts preconceptionally with gametogenesis in the parental reproductive organs and is followed by consecutive life course stages, such as conception, foetal and placental growth and development, menopause and geriatric aging. Each individual’s life course is unique. Therefore, the life course approach should be personalized and context-based, providing an individualized path towards healthy aging, with specific attention for prevention, the social environment and the next generation. A life course-long healthcare approach necessitates reorganisation of the current health care system, research and medical training programmes, involving integration and transcendence of transmural and multidisciplinary care as well as crossing medical, paramedical and social domains.

Knowledge of the functional anatomy of the pelvic organs with the surrounding tissues is a key element of safe clinical practice. The internal pelvic organs are firmly attached to each other and the encircling bony pelvic girdle and musculofascial pelvic floor by endopelvic fascia structures. This close relationship combining local anchoring and stretching properties of the mesenchymal tissues with the contractility of the pelvic floor is essential for good daily functioning of the male and female pelvic organs. In this chapter, the localization, composition of the organ tissues and changes during life are discussed in relation to their functions in urinary and faecal continence, vaginal delivery, fertilization, locomotion and how they prevent the formation of, for example, cystocele, enterocele, rectocele and vaginal prolapse. Attention is also paid to the development of the reproductive organs, which is essential to understand the wide range of variations and congenital malformations, but also to understand the complex anatomy of the pelvis with its vascularization and innervation patterns.

History taking is essential in gynaecology and obstetrics, both as a starting point for your diagnostic approach and in order to build a good relationship with the patient. The history should include a thorough medical, surgical, menstrual, and sexual history. Inquiries should be made into the patient’s home and work status, social history, and family history (past and present). The information you acquire during history taking in relation to the stage of life sets the context for the findings in the gynaecological examination. It is important to realize that the gynaecological examination is an intimate examination and can be stressful for the patient. Respectful contact, respect for privacy and a respectful approach are of key importance. The purpose of the examination of the female genitalia is to assess the female genital tract: the vulva, vagina, cervix, uterus, fallopian tubes and ovaries by means of inspection and when indicated, palpation of the external genitalia, inspection of the internal genitalia (with a speculum) and palpation of the internal genitalia (in a bimanual examination). Certain findings can help you in the diagnostic process by either including or excluding certain illnesses as the possible cause of symptoms. The examination can also play an important role in the assessment of lower abdominal pain and in screening for sexually transmitted diseases or cervical cancer.

The developmental origins of health and disease (DoHaD) paradigm states the relationship between prenatal exposures and offspring health in later life. So far this field of research has been mainly focused on the second half of pregnancy and the period just after delivery. From epidemiological and experimental studies, it has become clear that periconception conditions, such as age, ethnicity, chronic diseases, and genetic factors, as well as modifiable lifestyles, such as nutrition, smoking, and alcohol consumption, significantly contribute to human reproductive and obstetric health and performance. The periconception period represents the time span of 14 weeks before conception, in which both female and male gametes maturate, and the first 10 weeks after conception, during which implantation, early embryonic and placental development take place. Adverse preconception and periconception conditions and lifestyle can detrimentally affect these processes, which may have crucial consequences for fertility, prenatal growth and development, and the future health of the mother and her offspring during the life course. A new focus of reproductive and obstetric medicine should be the care and treatment of the couple before pregnancy: preconception care.

In this chapter normal foetal growth is described, starting from the embryonic period until delivery. Environmental and behavioural influences on growth are discussed and how these lead to abnormal growth patterns. An important subject is how to measure growth and how to discern normal deviations in size from abnormal growth. One of the important learning goals is to understand the pathophysiological processes of excessive growth and restricted growth, as well as their impact on outcomes in the immediate period of pregnancy and in later life. From this chapter, the reader will learn about the large influence of maternal behaviour, health and disease on offspring health. Lastly, the evidence on interventions to improve outcomes is discussed.

Foetal-to-neonatal transition during labour and just after birth is an intricate phenomenon in which many processes are involved. It is a vulnerable period for the newborn and perinatal mortality remains an important contributor to overall mortality and morbidity, despite improvements in foetal and neonatal care. In this chapter, the physiology of transition and potential diseases of the neonate are discussed. Important hallmarks of cardiopulmonary transition are the switch from foetal to postnatal circulation and aeration of the lungs, which also interact with each other. As perinatal asphyxia is an important risk factor for perinatal mortality and morbidity, neonatal resuscitation and pathophysiology of perinatal asphyxia are extensively discussed. The preterm born infant can encounter problems as a consequence of immaturity, such as respiratory distress syndrome and intraventricular haemorrhage. Insight into the physiology of transition at birth and the pathophysiology of common neonatal diseases is essential to improve neonatal and long-term outcome.

At birth atypical genitalia may indicate a disorder/difference of sex development, requiring referral to a specialized team. The hypothalamus-pituitary-gonadal axis is transiently activated after birth (minipuberty) and becomes quiescent during childhood. At this age vulvar itching and vaginal discharge are the most common gynaecological complaints. Puberty normally starts between age 8–13 years but can be precocious, delayed, absent or its course may be abnormal. In precocious puberty underlying central nervous system disorders should be ruled out. Absent or delayed puberty may be caused by hypogonadotropic or hypergonadotropic hypogonadism. Primary amenorrhoea may be present in these conditions but can also result from absence of a uterus and/or vagina or outflow tract obstruction. Children and adolescents may present with gender dysphoria which requires evaluation by a multidisciplinary team. In situations where future fertility may be affected, individuals should be counselled on fertility preservation options. Transition to adult services deserves careful preparation.

For most people sexuality is an essential aspect of quality of life. Sexuality is a bio-psycho-social phenomenon. All medical, psychological, social and relational events throughout the lifespan may impact sexual functioning and sexual wellbeing. As a result, sexual concerns and sexual dysfunctions are prevalent and often distressing. Usually, patients only present these problems when a health professional proactively enquires about the presence of any sexual difficulties.

According to incentive motivation theories, sexual desire should no longer be regarded as a spontaneous biological drive or ‘libido’ that precedes sexual arousal and that one has or does not have. Rather, desire for sexual activity is the result of competent sexual stimuli that activate the sexual response system, and mediated by the expectation that sex will be rewarding. Biological factors -neurotransmitters and hormones- do not ‘produce’ sexual desire but do determine the sensitivity of the sexual system for sexual stimuli. Based on these changed views, the distinction between arousal and desire has been abandoned in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The new diagnosis ‘female sexual interest/arousal disorder’ should not be made if the sexual difficulties are the result of inadequate sexual stimulation. If a sexual problem is situational, a biomedical cause is most unlikely. Dyspareunia, vulvodynia, and vaginismus are common sexual pain problems in women. Because differentiation between these problems is difficult, in DSM-5 these disorders are merged under the heading of ‘genito-pelvic pain/penetration disorder’. In sexual pain problems, penetration without sufficient lubrication and swelling of the clitoral complex, and insufficient relaxation of the pelvic floor are prevalent precipitating and maintaining factors. In primary dyspareunia, generalized pelvic floor overactivity is related to physical or psychological stressors that were present before sexual debut. In secondary dyspareunia and vulvodynia, pelvic floor overactivity is the consequence of repetitive painful experiences.

Whatever the initial precipitating factor(s) of a sexual dysfunction may be, there are always secondary psychological, relational and contextual maintaining factors that should be explored in the diagnostic and therapeutic process. Treatment of sexual disorders is, by definition, multidimensional, taking into account all possible predisposing, precipitating, maintaining and contextual factors. Therapy may include psycho-education, basic counselling, individual and couple psychosexual behavioural therapy, and hormonal and pharmacological treatment.

Effective and safe contraception protects women against physical, psychological and socioeconomic consequences of an unwanted pregnancy and against the major decision of induced abortion. In the Netherlands, more than 95 % of contraceptive advice and contraception itself is provided by general practitioners. In addition, in sexual health centres (GGD-Sense) young people under the age of 25 years can get contraceptive advice free of charge. Midwives are involved in discussing or providing contraception after the delivery and in the period between consecutive pregnancies. Gynaecologists are specialized in contraception for women with specific medical conditions or needs, and instrumental or surgical methods. All health workers should have sufficient knowledge about the advantages and disadvantages of the available contraceptive methods. The health worker should provide information on the different contraceptive methods to the individual woman. Above all else, the health worker should take care that this information is objective, understandable and also includes non-contraceptive benefits such as cycle regulation and prevention of sexually transmitted diseases. Choices will be made in accordance with the person’s wishes, possibilities, life course and medical prerequisites. Effective and safe contraception will be different for each individual.

The regulation of the menstrual cycle in women is an intricate interplay between the hypothalamic, pituitary and gonadal hormones. Immediately following menarche most menstrual cycles are anovulatory and hence the interval between menstruations is slightly irregular. After 2–4 years most girls will have regular periods. However, a small number will continue to have irregular or even absent menses. Other women will develop irregular cycles later on in life as they gain weight. In others the disappearance of menses might be associated with other disturbing symptoms. Anovulatory cycles are classified as having central, peripheral or combined causes. Apart from subfertility, anovulation is also associated with other short-term as well as long-term health issues such as hirsutism, obesity, metabolic syndrome, cardiovascular disease, osteoporosis and type 2 diabetes mellitus. Therefore, women with irregular menstrual cycles deserve proper medical attention, appropriate care and sufficient follow-up during their whole lifespan in order to prevent and timely treat some of the disturbing symptoms and health sequelae later on in life.

If a couple has failed to conceive spontaneously in 12 months of unprotected intercourse we speak of infertility. About 1 out of 7 couples seek medical guidance for infertility. Due to postponing childbearing this number might increase in the future. Infertility is a disability and should be investigated properly. Factors influencing fertility should be assessed and a work-up for both men and women should be performed. This includes a semen analysis, assessment of the menstrual cycle and evaluation of tubal pathology or other diseases that could influence fertility. If results reveal that a couple cannot conceive spontaneously, they are infertile and appropriate treatment should be offered. Idiopathic infertility means that no cause for infertility was found. In those cases a prognosis should be predicted to evaluate whether a couple should be advised to enter a fertility treatment program or still has sufficient chances of a spontaneous pregnancy within 6–12 months and should therefore be counselled for expectant management.

In vitro fertilization (IVF) – originally developed for the treatment of absolute tubal factor infertility – brings female and male gametes in close proximity in a petri dish outside the human body. Major steps in IVF include ovarian stimulation (aiming to stimulate maturation of multiple follicles), oocyte retrieval via transvaginal puncture to obtain multiple oocytes, fertilization of oocytes and the subsequent development of embryos under strictly controlled circumstances in the laboratory, the transfer of preferably a single, high-quality embryo into the uterine cavity and the freezing of surplus embryos, creating the possibility for additional chances of pregnancy when transferred in subsequent cycles. IVF success rates vary significantly, but current live birth rates are approximately 30 % per started IVF cycle; this represents a cumulative outcome involving the transfer of fresh and frozen embryos harvested from the same oocyte cohort. Intracytoplasmic sperm injection (ICSI) is the mechanical injection of a single sperm into the cytoplasm of an oocyte. This technology is able to generate pregnancies in couples with very poor sperm quality from their own genetic material. Such a sperm may be obtained from the ejaculate, or epididymal or testicular sperm may be obtained by surgical procedures. Currently, more than 60 % of all IVF cycles worldwide make use of the ICSI procedure. IVF can also be applied in many conditions not related to infertility per se, such as preimplantation genetic testing-diagnosis (PGT-D) of embryos in families with known congenital abnormalities, the preservation of fertility (for medical or non-medical reasons) by the cryostorage of ovarian tissue, oocytes or embryos, the use of donor oocytes or embryos, or the transfer of embryos into the uterus of another person allowing her (the ‘surrogate mother’) to carry the pregnancy.

Sexually transmitted infections (STIs) form a large burden for sexually active women globally. Public health efforts are of great importance to limit their detrimental effects at a population level. Both gynaecologists and obstetricians should be aware of the nature and adverse outcomes STIs can have in their patients. The asymptomatic nature of many STIs can hinder a timely diagnosis. In this chapter, key populations at risk for STIs and the most commonly used preventive interventions are highlighted. Subsequently the most common pathogens are discussed such as C. trachomatis, N. gonorrhoea, T. vaginalis, T. pallidum, herpes simplex viruses and human immunodeficiency virus (HIV). These pathogens are addressed where relevant in paragraphs that cover the syndromic spectrum of STIs: from lower tract infections such as vulvitis and vaginitis, to upper tract infections as cervicitis and pelvic inflammatory disease, to systemic infections caused by syphilis and HIV. Lastly, STIs in pregnancy are covered.

Antenatal care (ANC) comprises care in pregnancy for the pregnant woman and her foetus. The aim of ANC is to promote the best possible biological, emotional and social outcome of pregnancy for both. This chapter is a description of routine and specialized antenatal care such as testing for chromosomal abnormalities of the foetus and foetal therapy that may be offered to every pregnant woman, aiming to promote health and the best possible pregnancy outcome, and to prevent gestational disease and adverse outcome. Care for specific groups of pregnant women, such as women with early pregnancy disorders, gestational disease or chronic maternal disease, is described elsewhere in this book in Chap. 19 and Chap. 20 whereas preconception and periconception care are described in Chap. 6.

The functional and subjective changes in the mother around her pregnancy are profound and may resemble signs and symptoms of diseases. Equally impressive is the quick return to a pre-pregnancy situation after delivery. These adaptations affect nearly every organ system and are essential for normal maternal pregnancy and normal foetal development. Changes in eating habits are one of the first physiological symptoms of pregnancy. During pregnancy, the maternal body weight increases by on average 12 kg. The importance of the placenta is well recognized. Pregnancy is characterized by a hyperdynamic cardiovascular state. Peripheral insulin resistance becomes more prominent during pregnancy making pregnancy a state of hyperinsulinism with increased glucose levels. Respiration is more efficient during pregnancy, although most pregnant women have a subjective feeling of mild dyspnoea. From early pregnancy onwards there is a substantial increase in renal plasma flow. Nowadays the importance of the human microbiome for normal development of pregnancy is well realized.

Early pregnancy, starting at conception and ending with the completion of embryogenesis, is a period of rapid growth and development of both embryo and placental tissues. Early disruption of embryonic development has major consequences, which are discussed in this chapter. Gestational trophoblast disease is rare and occurs when the embryo’s genetic material is polyploid or of monoparental origin, and can result in gestational trophoblast neoplasm. Miscarriage is common and reflects early embryonic developmental arrest and demise, e.g. due to chromosomal abnormalities. Ectopic pregnancy occurs when implantation takes place at any site other than the uterine cavity, usually the fallopian tube. Each of the disorders frequently present with bleeding in early pregnancy. Finally, and in contrast to the previous three disorders, hyperemesis gravidarum, or excessive vomiting in pregnancy, is likely a result of the surge in placental hormones in early pregnancy that marks a healthy placental development.

Gestational disorders are diseases related to pregnancy. The most common gestational disorders include hypertensive diseases and preterm birth. Both have a major impact on women and their children’s life shortly after pregnancy as well as in later life. Other gestational diseases that will be discussed are gestational diabetes, cholestasis of pregnancy, amniotic fluid embolism, thrombosis, urinary tract infection and trauma. The different pathophysiological mechanisms, treatment options and consequences for these pregnancy-related disorders will be described.

This chapter addresses the most common risk factors increasing maternal and offspring health disadvantages. Psychosocial vulnerability, including maternal stress and substance abuse, overweight and obesity, psychiatric disorders, chronic and acute infections, autoimmunity, chronic kidney disease and hypertension, cardiac disorders, either acquired or congenital, and diabetes mellitus are systematically evaluated on the effect of the condition on pregnancy and vice versa, and the possible effect of specific disease-modifying drugs.

Labour is a physiological process during which the foetus, membranes, umbilical cord and placenta are expelled from the uterus. After the birth of the placenta and membranes, childbirth ends and the postpartum period begins. The course and outcome of labour and delivery is influenced by many factors, originating from mother and foetus but also by the attending care provider(s). Care during childbirth should find a good balance between too little, too late and too much, too soon. Barrier-free collaboration of all care providers involved in maternity care is required in order to provide good-quality, woman-centred birth care. Adverse perinatal and/or maternal outcome, including a negative birth experience, may have lifelong consequences. In this chapter the mechanisms of normal and abnormal labour, delivery and puerperium are described as well as the relevant factors contributing to a normal or abnormal course of delivery and its consequences.

Abnormal menstrual bleeding (AUB) is a collective name for all vaginal bleeding problems such as heavy menstrual bleeding, intermenstrual bleeding, spotting and postmenopausal bleeding. To address AUB the classification of the International Federation of Gynaecology and Obstetrics (FIGO) is used worldwide. In 2011 the FIGO also developed a new classification system for the causes of AUB, the PALM-COEIN; polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified. The PALM part of this classification denotes the anatomical causes and the COEIN part stands for the essential causes of AUB. History and examination are the basis of investigation. Moreover the pictorial blood assessment chart gives an indication about the amount of blood lost each month. Several imaging tests (e.g. transvaginal ultrasound, hysteroscopy, MRI) are used to visualize the cause of AUB, followed by an individual tailored solution depending of the underlying cause.

The pelvic floor, consisting of muscles and connective tissue, plays a crucial role in a woman’s life. Basically, the pelvic floor has two functions. It must support the pelvic organs such as the bladder, anorectum and vagina against a rise in intra-abdominal pressure. It does so by providing basic support and contraction at appropriate moments. On the other hand, it must allow the passage of urine and faeces, and allow pain-free sexual intercourse. Life events as childbirth and menopause are likely to affect normal functioning. Dysfunction of the pelvic floor is the field of the subspecialty urogynaecology.

Benign pelvic masses can be of uterine or ovarian origin. Benign uterine masses such as uterine fibroids usually cause additional symptoms such as abnormal vaginal bleeding (chap. 22). There are numerous types of benign cysts. Functional cysts include follicular and corpus luteum cysts. Neoplastic cysts include epithelial tumours, sex cord-stromal tumours, or germ cell tumours. The most common types are the mature teratomas, serous and mucinous cystadenomas and the ovarian fibromas. For optimal treatment of ovarian masses, accurate differentiation between a benign and malignant mass with ultrasound is indispensable. Besides subjective assessment, there are many ultrasound models available to aid the clinician with this differentiation. The most promising models are the IOTA models: logistic regression 2 (LR2) model, Simple Rules, and Assessment of Different NEoplasias in the adneXa (ADNEX) model. The decision whether to operate depends on the symptoms, the subtype, the size, the patient’s menopausal status, and whether there is doubt about the nature of the mass. If surgery is indicated, the route of surgery (laparoscopy versus laparotomy) and extent of surgery (cystectomy versus ovariectomy) should be decided.

Cervical premalignancies are caused by an asymptomatic infection with high-risk human papilloma virus (hr-HPV). Most women clear these infections; however, a subset remains infected. Such an infection can lead to premalignancies, which can be picked up by the national screening program with PAP smears. Women with abnormal PAP smears are referred, by their general practitioner, to the gynaecologist for a colposcopy. When abnormalities are detected, biopsies are taken to histologically confirm the suspicion. High-grade lesions are treated by removing the abnormal area by a loop electrosurgical excision procedure (LEEP). If a high-grade lesion remains undetected or is left untreated, cervical cancer may develop. Nowadays, vaccination against hr-HPV may prevent this type of tumour. In case of diagnosis of cervical cancer a systematic, multidisciplinary workup is needed. The FIGO stage of disease needs to be established and is purely based on physical examination. In the Netherlands an MRI scan of the small pelvis is recommended in suspected early stage disease. In case of suspected higher stage disease a PET-CT scan is warranted. Surgery is the cornerstone of curative treatment in localized disease. With locally advanced disease, chemoradiation therapy with curative intent is the cornerstone of treatment. Prognosis for early stage disease is very good.

Worldwide, breast cancer is the most frequently diagnosed cancer. In the Netherlands, 1 in 8 women will be diagnosed with breast cancer at some point during life, corresponding with a cumulative life time risk of 12–13 %. Approximately 75 % of the newly diagnosed breast cancer patients are aged 50 or older. Approximately 7 % are less than 40 years. These young women with breast cancer comprise a particular subset due to the often more aggressive biology of their tumours as well as their unique psychosocial concerns. They are at a higher risk of carrying a high-risk allele for hereditary breast cancer and will be offered counselling by a clinical geneticist irrespective of their family history. Young women, who are often advised to have systemic chemotherapy, can be confronted with treatment-related infertility and/or premature ovarian failure. Therefore counselling by gynaecologists, in close collaboration with medical oncologists, is immediately offered after diagnosis if they want to have children. Young women can suffer various other long-term physical and mental side effects of oncological treatment. Problems related to premature ovarian failure include menopausal symptoms such as hot flushes, genitourinary problems, psychological and psychosexual difficulties, and accelerated loss of bone mineral density. Premature menopause may contribute to increased cardiovascular morbidity.

Menopause is a transition phase. Four out of five women experience some kind of discomfort and one third of these women experience serious complaints. Vasomotor symptoms are the most common complaints, but also menstrual disorders, mood swings, joint problems, urovaginal symptoms, or sexual disorders may occur. For these women the menopause has a serious impact on quality of life and consecutively societal consequences. Several treatment options are available. To date there is overwhelming scientific evidence that the benefits overweigh the risks of menopausal hormonal therapy (MHT). In the past, following the WHI study risks have been overrated or incorrectly interpreted. It is of importance that prescribing MHT should be individualised, based on the type of complaints, individual preferences and risks. Non-hormonal alternatives are available but merely not evidence-based, less effective and not always safe. For all women after menopause, healthy aging and prevention of chronic diseases is of the essence. Thus a life course approach can be of importance to make it possible to anticipate and so take prevention measures for chronic diseases with high morbidity and mortality risk, such as gender specific cardiovascular diseases and osteoporosis.

Endometrial cancer is the most common malignancy of the female genital tract with rising incidence due to increased life expectancy and obesity. Most women presenting with postmenopausal bleeding are diagnosed at an early stage with a favourable outcome. Yet, a significant number of patients have advanced stage disease, or present with recurrent disease, and have limited treatment options. Primary treatment consists of hysterectomy and salpingo-oophorectomy, preferably by a minimal invasive approach. Lymph node dissection is recommended for patients with grade 3 endometrioid, serous and clear cell histology, since these patients are at significant risk of extended disease. Adjuvant radiotherapy can improve local control in a subgroup of patients. Chemotherapy is recommended for patients with metastatic disease. Alternatively, hormonal treatment can be effective with less side effects, but development of resistance to hormonal treatment limits the duration of effect. Prevention of endometrial cancer may be accomplished by a healthy lifestyle and improving the body weight.

Ovarian cancer is a relatively uncommon type of cancer. Factors that increase the risk of developing epithelial ovarian cancer are early menarche, nulliparity, late menopause, increasing age and inherited predisposition. Around 90 % of malignant tumours in the ovaries are epithelial in origin; other types include non-epithelial and metastatic tumours. The epithelial ovarian cancers form a heterogeneous group with high-grade serous carcinoma as the most common subtype. This subtype most likely originates from the epithelium of the distal fallopian tube. Due to a lack of specific symptoms the majority of patients with ovarian cancer are diagnosed with advanced stage of the disease. In most European countries, therapy for patients with ovarian cancer has been centralized to specialized hospitals ensuring higher case volumes and concentration of expertise. Standard therapy for ovarian cancer comprises a combination of surgery and chemotherapy. Despite an initial response, patients frequently develop resistance to chemotherapy. The prognosis of patients with ovarian cancer is therefore unfavourable. Innovative therapeutic strategies, for example based on molecular subtyping, are required to improve treatment outcome.

Vulvar malignancies are rare with squamous cell carcinoma (SCC) as the most common histological type. Vulvar basal cell carcinomas and melanomas are even more rare. In general, vulvar cancer is a disease of the elderly woman but the incidence is increasing, especially in younger women. There are two oncogenic pathways of vulvar SCCs, both with their own premalignancy, but with comparable treatment until now. Surgery is the cornerstone of treatment consisting of excision of the primary tumour with groin surgery. This leads to a 5-year survival rate of around 70 %. The treatment of vulvar cancer has an enormous impact on the psychosexual quality of life. Lichen sclerosus, vulvar high-grade squamous intra-epithelial lesion (HSIL), differentiated vulvar intraepithelial neoplasia (dVIN) and Paget’s disease of the vulva are all vulvar premalignancies with a broad spectrum of symptoms. Dedicated multidisciplinary teams are necessary to optimize cure and care for women with vulvar cancer and vulvar premalignancies.

The majority of older people are female, due to the higher maximum lifespan of the aging female. Despite their higher life expectancy, older women suffer from more diseases and impairments, which together form the second leading cause of the increasing portion of health services directed towards aging female patients. In old age, a problem-based, generalist approach can be complementary to a disease-specific approach. In this chapter, we present such a generalist approach to complement the disease-specific approach presented in the rest of the book. We clarify the various interactions between aging and diseases, as well as between gynaecology and age-related impairments in the physical, psychological, social domains. The chapter starts with a discussion of the most important mechanisms and theories of aging, relating them to the aging female genital system, along with gynaecological interventions. After reading this chapter, readers should be able to describe the most important general characteristics of the aged female patient: increasing heterogeneity, multimorbidity, high incidence of geriatric syndromes and the atypical presentation of common diseases. The chapter also explains specific aspects of communication with and general examination of elderly women. It will help readers to understand and apply specific features of the diagnostic and therapeutic approach to frail older women. Finally, after studying the text, readers should be able use principles of care that will improve the effectiveness and efficiency of gynaecology for older women.