Managing Gynaecology Malignancies During Pandemic


Women with gynaecological conditions may be delayed from getting medical attention due to MCO travel restrictions or health personnel being diverted to combat Covid-19.

The world is now busy fighting the Covid-19 pandemic. The end is nowhere near although the recent news on vaccines being developed is encouraging.

However, we know that other medical conditions – be it infective, non-communicable or malignancies – continue to occur in our community. Death or morbidities arising from these conditions still continue among those affected.

Delay in getting medical attention is common during this pandemic and could be due to movement restriction, economic reasons, or the inability of health authorities to cope with the demand, in the face of Covid-19.

All malignancies tend to have a protracted management – from diagnosis to treatment and follow up.

The ability to detect precancerous conditions and treating them well can contribute towards overall lower costs of management, earlier and healthier return to employment when the situation improves, and less burden on national healthcare.

This situation is well portrayed in certain gynaecological malignancies. Recognition of these situations by public and health personnel will hopefully increase their awareness and prompt the affected individuals to seek earlier appropriate medical attention.

Cervical malignancy

There is a very clear precancerous situation for this condition. It usually has no symptom but easily detectable by cervical Pap smear.

Self-sampling has been available in certain centres thus the embarrassing situation of pelvic examination by doctors can be avoided.

Precancerous lesions are easily treatable, curable and with very low morbidity, and can even preserve fertility.

However, delay in seeking treatment could lead to cancer development, very messy symptoms and its long protracted treatment, with reduction in productivity of the patient and her spouse too.

Nowadays, human papilloma virus (HPV) vaccination is widely available.

Married women or those with confirmed treated precancerous lesion can gain protection against new infection by the high-risk HPV which is the known cause of cervical cancer.

Endometrial malignancy

This is another common female genital tract malignancy.

Recent experience showed that more younger women are affected, as a result of their underlying risks profile.

It also has a recognisable precancerous stage (endometrial hyperplasia) but there is no recommended screening method.

Risks profiles include those who are overweight, have diabetes, polycystic ovarian syndrome (PCOS), fertility issues and excessive menstrual or postmenopausal bleeding.

These are symptoms or risks that can be used as markers to get women to seek earlier medical attention.

Assessment of the endometrial lining to rule out hyperplasia or malignancy is the single most important investigation.

Treatments of precancerous stage or even early cancerous are easy, effective and curative.

Ovarian malignancy

The overall life time risk of developing ovarian malignancy is less than 2%. It affects elderly women, although certain types are more common in younger women.

Usually there is no specific symptom apart from some fullness, discomfort or dyspepsia. Loss of weight, appetite and abdominal distension are late signs once cancer is already at stage three. It has no precancerous stage, thus there is no recognised screening method.

However, certain conditions are known to be associated with an increased risk, such as women with recurrent endometriosis, childlessness, obesity and those with close relatives who had breast or ovarian cancers (BRCA mutation).

Despite no recognised screening method, opportunistic pelvic ultrasound and bimanual examination during routine screening for Pap smear is highly recommended.

Blood CA 125 is non-specific and tends to be raised at a much later stage. Earlier detection is desirable as it may enable fertility sparing treatment and even if definitive surgery is employed, it tends to be easier with less morbidity.

Uterine fibroids and sarcoma

Up to 70% of women would have fibroids, with 50% of them asymptomatic. Those with symptoms tend to have heavy and painful menses.

Treatment for symptomatic fibroid is simple and chosen based on age, parity, size, location, type and severity of symptoms.

Surgery is always the last resort after failure of other conservative methods.

Sarcoma is a rare development of cancer from the fibroid and usually happens in elderly women, with significant progressive enlargement of the uterus or slow onset of weight loss being the most common symptoms.

Diagnosis is difficult and normally made after hysterectomy. MRI can help to diagnose complex and highly vascular fibroid with special features before surgery.

Therefore, those with large fibroids should consult their gynaecologists regularly to ensure they remain just fibroids.

Conclusion

These are common gynaecological conditions that may be affected by the delay or troublesome provision of healthcare to affected individuals.

Similar arguments are valid for all other malignancies known to us. Awareness and recognition of all the factors and high risk situations described above may help to prompt earlier medical attention and avoid unnecessary morbidity and mortality.

Dr Noor Azmi Mat Adenan is a consultant gynaecologist and gynae oncologist, Ara Damansara Medical Centre.

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