Textbook of Obstetrics and Gynaecology

This chapter presents the future perspectives of a life course approach in obstetrics and gynaecology.

Women’s reproductive health is a major determinant for pregnancy outcomes and risk of non-communicable diseases in later life. Besides having consequences for a woman’s personal health, it also has important consequences for the health of her offspring. Adverse maternal exposures during pregnancy may adversely affect foetal development, leading to permanent developmental adaptations that predispose offspring to an increased risk of non-communicable diseases in adulthood. In using this life course approach to women’s health, we need to identify and create opportunities to improve women’s health through their lives and the health of future generations, both at the population level and 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 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 ageing. Every individual’s life course is unique. Therefore, the life course approach should be personalised and context-based, providing an individualised path towards procreation, healthy ageing, with specific attention for prevention, the social environment and the next generation. A life course-long healthcare approach necessitates the 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 into 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, 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 localisation, composition of the organ tissues and changes during life are discussed in relation to their functions in urinary and faecal continence, vaginal delivery, fertilisation, 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 and the complex anatomy of the pelvis with its vascularisation and innervation patterns.

History taking is essential in gynaecology and obstetrics, 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. Make sure you understand the patients request for help. Inquiries should be made into the patient’s home and work status, social history, cultural aspects 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 realise 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, either by 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.

This chapter presents the future perspectives of conception and foetal health.

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 critical time span of 14 weeks before conception, in which both female and male gametes maturate, followed by the first 10 weeks after conception during which implantation and the early embryonic and placental development take place. Adverse conditions and lifestyle behaviour during these 24 weeks can detrimentally affect these biological processes with consequences for fertility, prenatal growth and development, and the health of the mother and her offspring during the life course. A new focus of reproductive and obstetric medicine should be the preventative 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, as is how these lead to abnormal growth patterns. An important subject is how growth should be measured and how normal deviations in size should be discerned from abnormal growth. One of the important learning goals is understanding 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. This chapter discusses the large influence of maternal and paternal conditions, health and lifestyle on offspring health. Lastly, the evidence on interventions to improve outcomes is discussed.

The foetal-to-neonatal transition during labour and just after birth is a complicated phenomenon in which many processes are involved. It is a vulnerable period for the new-born 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. As perinatal asphyxia is an important risk factor for perinatal mortality and morbidity, neonatal resuscitation and pathophysiology of perinatal asphyxia are discussed extensively. 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 outcomes.

This chapter presents the future perspectives of childhood and adolescence.

At birth, atypical genitalia may indicate a difference of sex development, requiring referral to a specialised 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, if medical treatment is requested, 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 part of quality of life. Sexuality is a biopsychosocial 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 inquiries 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 is mediated by the expectation that sex will be rewarding. Biological factors – neurotransmitters and hormones – do not ‘produce’ sexual desire, but they do determine the sensitivity of the sexual system to sexual stimuli. Based on these changed views in DSM 5, the distinction between arousal and desire has been abandoned. 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 highly unlikely. Dyspareunia, vulvodynia and vaginismus are common sexual pain problems in women. Since 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, generalised pelvic floor overactivity may be related to physical and/or psychological stressors that were present before sexual debut. In secondary dyspareunia and vulvodynia, pelvic floor overactivity can be the consequence of repetitive painful experiences.

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

Transgender and gender-diverse individuals have a gender identity that differs from the sex assigned at their birth. Depending on the needs of each individual, medical and/or surgical gender affirming treatment may be provided. Transition may impact a person’s reproductive options, so fertility counselling and preservation should be available. People of all gender identities with a uterus can become pregnant, and they may need specific obstetric guidance. The aetiology of gynaecological complaints does not differ much from the cisgender population and warrants all social and health care employees to take a trans-specific and gender-inclusive medical approach. To address the specific health concerns and needs of transgender and gender-diverse people, it is of the utmost importance that all health care providers are educated and trained in transgender health.

Effective and safe contraception protects women against physical, psychological and socioeconomic consequences of unwanted pregnancy and against the major decision of induced abortion. In the Netherlands, more than 95 % of contraceptive advice and contraception 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. Gynaecologists are specialised 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. Health workers 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 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, sexual lifestyle, possibilities, life course and medical prerequisites. Effective and safe contraception will be different for everyone.

This chapter presents the future perspectives of reproductive health.

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 two to four 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 if they gain too much 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.

Infertility is defined as failure to conceive spontaneously in 12 months of unprotected intercourse. Approximately one out of seven couples seek medical guidance for infertility. Due to postponing childbearing, this number may increase in the future. Infertility is a disability and should be investigated properly. Factors that influence fertility should be assessed and a work-up for both men and women should be performed. This includes a semen analysis, assessment of ovulations 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 these cases, a prognosis should be predicted to evaluate whether a couple should be advised to enter a fertility treatment programme or still has sufficient chances of a spontaneous pregnancy within 6–12 months and should therefore be counselled for expectant management.

In vitro fertilisation (IVF) – which was originally developed for the treatment of tubal factor infertility – brings female and male gametes into 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, fertilisation 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. This sperm may be obtained from ejaculate or, alternatively, epididymal or testicular sperm may be obtained by surgical procedures. Currently, more than 70 % 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 (PGT) of embryos in families with known monogenic or structural chromosomal rearrangements. Moreover, the preservation of fertility for medical or non-medical reasons by the cryo-storage of ovarian tissue, oocytes or embryos is one of the possibilities created by the IVF techniques. Finally, the use of donor oocytes or embryos, opens up the possibility to become pregnant for those women without oocytes. The transfer of embryos into the uterus of another person, allowing the ‘surrogate mother’ to carry the pregnancy for women without a womb is a possibility due to the IVF technique.

Genital infections, especially 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 the population level. Both gynaecologists and obstetricians should be aware of the nature and adverse outcomes STIs, and other genital infections can have in their patients. The asymptomatic nature of many genital infections 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, including 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, including genital tuberculosis, to systemic infections caused by syphilis and HIV. Lastly, STIs in pregnancy are covered.

This chapter presents the future perspectives of maternal adaptation to pregnancy.

Antenatal care (ANC) comprises care in pregnancy for the woman and her foetus. The aim of ANC is to promote the best possible biological, emotional and social outcome of pregnancy for the mother and her child. This chapter is a description of routine and specialised antenatal care such as testing for 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. 25 and 28 whereas preconception and periconception care are described in Chap. 8.

The functional and subjective changes in the mother around her pregnancy are profound and even 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 recognised. Pregnancy is characterised 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 realised.

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, in some cases leading to intra-abdominal bleeding. 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 lives shortly after pregnancy, as well as in later life. Other gestational diseases discussed are gestational diabetes, cholestasis of pregnancy, amniotic fluid embolism, thrombosis and urinary tract infection. The different pathophysiological mechanisms, treatment options and consequences for these pregnancy-related disorders are also described.

In this chapter, all relevant aspects of multiple pregnancy are discussed: from conception to postnatal care. The management of multiple pregnancies relies on chorionicity due to the different prevalence of prenatal and perinatal complications. Preterm birth is the most important determinant of adverse perinatal outcomes in twins. The additional increased morbidity and mortality rates in monochorionic twins are related to vascular anastomoses, which can result in Twin-Twin Transfusion Syndrome (TTTS), Twin Anaemia Polycythaemia Sequence (TAPS) and Twin Reversed Arterial Perfusion (TRAP). Knowledge of the underlying mechanisms will help to guide women with multiple pregnancies safely through pregnancy and childbirth. The incidence of twins worldwide is highly associated with ART.

The placenta is one of the biggest organs during pregnancy and plays a crucial role in the development of a healthy foetus. It is an indispensable part of the pregnancy with valuable functions in the development and protection of the foetus. Many problems can occur that impair placental function. For example, placental abnormalities in location and invasion, such as placenta previa, low-lying placenta, vasa previa and placenta accreta spectrum disorders. A placenta previa and low-placenta are lying in the lower uterine segment and overly the internal os of the cervix, a placenta previa, or are positioned close by the internal os of the cervix, low-lying placenta. In women with vasa previa, the foetal blood vessels that connect the umbilical cord and the placenta are located in the membranes and overly the internal os of the cervix. In placenta accreta spectrum disorders the placenta adheres or invades in an abnormal way to the uterine wall. These abnormalities can result in foetal and maternal complications during pregnancy. Therefore, it is important to have knowledge of, recognise and understand these abnormalities.

This chapter addresses the most common risk factors increasing maternal and offspring health disadvantages. Psychosocial vulnerability, including maternal stress, 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 for their effects on pregnancy and vice versa, and the potential effects of specific disease-modifying drugs.

Labour is a physiological process during which the foetus and placenta with membranes and umbilical cord, 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 birth is influenced by many factors, originating from mother and foetus but also from the attending care providers. Care during childbirth should strike a good balance between being too little, too late and too much too soon. Barrier-free collaboration of all care providers involved in maternity care is necessary 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, birth and puerperium are described, as well as the relevant factors contributing to a normal or abnormal course of childbirth and its consequences.

Emergencies can occur during pregnancy, childbirth or postpartum, and they can endanger the health of both mothers and their babies. This may result in maternal and/or perinatal mortality or severe morbidity. Adequate management is essential and can substantially improve outcomes for both mother and child. The structured method for assessing critically ill patients consists of a primary and secondary survey. The primary survey follows the ABCDE approach, which is based on the ‘treat first what kills first’ principle. This uniform approach enables the systematic and timely assessment of potential life-threatening conditions during an emergency and facilitates communication between different caregivers. In this chapter, we describe several obstetric emergencies and provide a structured proposal for the management of these emergencies.

This chapter presents the future perspectives of reproductive ageing.

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 visualise the cause of AUB, followed by an individual tailored solution depending on 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. 32). There are numerous types of benign ovarian masses. Functional cysts include follicular and corpus luteum cysts. Neoplastic masses 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. In addition to 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.

Endometriosis is a benign gynaecological disorder, characterised by endometrial-like tissue growing outside the uterine cavity under the influence of oestrogens. It affects 2–10 % of women of reproductive age. The exact pathogenesis is not entirely clear, but a complex multifactorial process of immunologic, inflammatory and hormonal factors seems to be involved. Endometriosis can be suspected based on clinical symptoms and findings by physical examination and/or imaging modalities. Surgical identification, including histological verification, is no longer the gold standard for the diagnosis. Currently, laparoscopy is recommended only in patients with negative imaging and/or where empirical treatment has failed. Since curative treatment options for endometriosis are not available, treatment is challenging. Symptomatic treatment of this chronic disease consists of analgesia, hormonal suppression therapy and surgical intervention. In infertile women, assisted reproductive techniques may be considered. A multidisciplinary and life course approach is advocated.

Cervical premalignancies are caused by an asymptomatic infection with high-risk human papilloma virus (hr-HPV). Most women clear these infections, but a subset remains infected. This kind of infection can lead to premalignancies, which can be picked up by the national screening programme with PAP smears. Women with abnormal PAP smears are referred to a gynaecologist for a colposcopy by their general practitioner. If 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) or regress with imiquimod immunomodulating cream. If a high-grade lesion remains undetected or is left untreated, cervical cancer may develop. Nowadays, vaccination against hr-HPV can 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 based on physical examination and imaging. In the Netherlands, an MRI scan of the pelvis is recommended in suspected early-stage disease. In case of suspected higher stage disease, an additional PET-CT scan is warranted. Surgery is the cornerstone of curative treatment in localised disease. With locally advanced disease, chemoradiation therapy with curative intent is the cornerstone of treatment. Prognosis for early-stage disease is very good.

This chapter presents the future perspectives of peri- and postmenopausal health

Worldwide, breast cancer is the most frequently diagnosed cancer. In the Netherlands, 1 in 7 women will be diagnosed with breast cancer at some point during life, corresponding with a cumulative lifetime 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 in the future. 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 menstrual disorders, mood swings, joint problems, urovaginal symptoms, mental health problems, sleeping and sexual disorders may also 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 outweigh 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. For all women after menopause, healthy ageing and prevention of chronic diseases is of the essence. Thus a life course approach is important to be able to proactively take preventive measures for chronic diseases with high morbidity and mortality risk, such as gender specific cardiovascular diseases, mental health disorders 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 (high risk of) endometrial cancer may be accomplished by a healthy lifestyle and improving body weight.

Ovarian cancer is a relatively uncommon type of cancer, and the most common form of it (90 %) is epithelial. Other histotypes include non-epithelial and metastatic tumours. Epithelial ovarian cancers form a heterogeneous group with high-grade serous carcinoma (HGSC) being the most common subtype, which we now assume originates in the distal part of the fallopian tube. In the absence of specific early symptoms, most patients with ovarian cancer are diagnosed with advanced stage disease. Standard therapy for ovarian cancer comprises a combination of surgery and chemotherapy. In most European countries, surgical therapy for patients with ovarian cancer is centralised in specialised hospitals, which often provide chemotherapy in conjunction with neighbouring hospitals. This allows more cases to be handled and surgical expertise to be concentrated. Despite an initial response, most patients develop resistance to chemotherapy. The prognosis of patients with ovarian cancer is therefore unfavourable and ten-year survival has not improved recently. Innovative therapeutic strategies – such as ones based on genetic and molecular subtyping – are increasingly being developed 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 found in elderly women, but 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 five-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 range of symptoms. Dedicated multidisciplinary teams are necessary to optimise curing and caring for women with vulvar cancer and vulvar premalignancies.

Most older people are female due to the longer maximum lifespan of women. Despite their longer 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 ageing female patients.

In old age, a problem-based, generalist approach can be complementary to a disease-specific approach. In this chapter, we present one such generalist approach to complement the disease-specific gynaecological approach dominantly present in the rest of the text. We clarify the various interactions between ageing and diseases, as well as between gynaecology and age-related impairments in the physical, psychological and social domains.

The chapter starts with a discussion of the most important mechanisms and theories of ageing, relating them to the ageing 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, multi-morbidity, 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.