**10. Vulvar abscesses**

when cyclical, may be caused by endometriosis, and it is the underlying cause of pelvic pain in 15% of cases [36]. The exact prevalence is unknown because surgery and/or histology is required for its diagnosis, but estimates of 3-10% of women in the reproductive age group, and

The symptoms of endometriosis and the laparoscopic findings do not always correlate [38]. The focus during management should be on the illness rather than the disease. There is no place for medical treatment of endometriosis with drugs in infertile women desirous of having babies [39]. Surgery can be done via laparotomy or laparoscopy [40, 41]. Analgesics are often required for symptomatic relief of pain. Unlike infection, endometriosis does not damage the luminal epithelium of the fallopian tube, and thus conservative surgery is more likely to be successful in restoring normal anatomic relations. However, endometriosis is also a well

Severe vaginal bleeding may or may not be related to menstruation. Common causes are dysfunctional uterine bleeding (DUB), uterine fibroids, adenomyosis and genital tract

Normal menstrual cycles range from 21-35 days, with the estimated blood loss less than 80 ml, with flow not more than 7 days. Most women who complain of heavy periods have normal loss. Extremely heavy menstrual loss is uncommon and other causes such as a miscarriage or a genital tract malignancy like carcinoma of the cervix or endometrial carcinoma should be ruled out. If the patient is symptomatic after a heavy menstrual loss, like having dizziness or fainting spells, appears pale or has tachycardia, she should be admitted to hospital for

Patients with massive vaginal bleeding require resuscitation which includes securing of intravenous access with a wide bore cannula, obtaining blood samples for a complete blood count and infusing of crystalloids. Possible causes of the vaginal bleeding should be ruled out.

Control of bleeding may be achieved by use of haemostatic drugs like tranexamic acid (an antifibrinolytic agent) and ethamsylate, or by hormonals like medroxyprogesterone, prior to definitive treatment of the cause. Mirena, a levonorgestrel-impregnated intrauterine system, and endometrial ablation techniques like the NovaSure system may also be employed [42] for

The definitive treatment is dependent on the cause and emergency dilatation and curettage (D&C), myomectomy, and even a hysterectomy (Fig. 4) are possibilities. For those emanating from gynaecological cancers referral to oncology units with expertise in their management is

There is the need to correct anaemia with haematinics and even blood transfusion.

25-35% of infertile women have been made [37].

known cause of frozen pelvis.

42 Contemporary Gynecologic Practice

**9. Severe vaginal bleeding**

malignancy.

treatment.

control of bleeding.

required.

Bartholin's cysts are the commonest cysts of the vulva, and they are of two types, a cyst of the duct and a cyst of the gland, with differentiation made on histology using the surface epithelium. The position of the swelling at the junction of the anterior two-third and the posterior one-third of the labia majora is diagnostic. Bartholin's abscesses are secondarily infected cysts. Organisms involved in the infection of the gland are similar to those responsible for PID [43, 44].

Drainage should be established whenever an abscess develops. Apart from the pains, which may be severe, there is the theoretical risk of ascending infection, with a more extreme inflammatory process, with systemic symptoms and signs of infection, and these may affect the quality of life. Cases of necrotizing fasciitis have been reported in immuno-compromised women, including those with diabetes mellitus. Septic shock and toxic shock-like syndrome can also complicate Bartholin's abscess [45], [46].

The treatment of Bartholin's abscess encompasses bed rest, use of antibiotics and analgesics, coupled with surgical drainage and warm sitz bath. The procedure of choice for surgical drainage is marsupialization, and this has the advantage of preserving the gland, which continues its secretory function and prevents recurrence by the creation of a new gland ostium or fistula to replace the function of the presumed damaged or obstructed duct. Simple incision and drainage (I&D) of the abscess is associated with a high recurrence rate.

Abscesses that rupture spontaneously are treated by warm sitz bath. Gland excision is not recommended for Bartholin's abscess because of the risk of spread of infection which may result following surgery in an inflamed hyperaemic tissue environment [47].

Another less common vulvar abscess is that involving the Skene's gland. Treatment basically follows the same principles as that for Barthoin's abscess.
