**6. Uterine fibroids**

There is the need to send the specimen obtained from uterine evacuation for pathological analysis and for cervical/vaginal cultures to be obtained in cases of infection. Histopathological study may also exclude gestational trophoblastic diseases which can present in a similar manner to the miscarriages, may require suction evacuation of the uterus, but also do require

Based on the history pelvic pain could either be cyclical or non-cyclical. Cyclical pain is commonly as a result of pre-menstrual syndrome, pelvic endometriosis, primary dysmenor‐ rhoea and ovulation pain (Mittelschmerz). For non-cyclical pain the common causes include pelvic inflammatory disease (PID), severe endometriosis, pelvic tumours, pelvic congestion syndrome and surgical causes like appendicitis and diverticulitis. A good history is required to make a possible diagnosis. The nature of the pain, whether cyclical or non-cyclical, acute or chronic (if present for 6 months or more), severity and exacerbating and relieving factors should be noted. Other associations to be noted include the parity, vaginal discharge, abnormal vaginal bleeding, dyspareunia, urinary symptoms, gastrointestinal symptoms, loss of appetite,

Examination of the patient would involve general and systemic examinations, most especially the abdomen, pelvis and vagina. Pallor, wasting, abdominal distension, masses in the abdomen

For the investigations, ultrasonography of the abdomen and the pelvis plays a key role. A growth in the lower genital tract may require a biopsy, and tumour marker screen for cancer antigen 125 (CA-125), carcino-embryonic antigen (CEA) and alpha feto-protein (AFP) may be required for pelvic tumours. A complete blood count, C-reactive protein and urine culture are often required. Diagnostic laparoscopy, when available, is a positive addition in the manage‐ ment of chronic pelvic pain when there is diagnostic difficulty, but not forgetting idiopathic

Tumours of the ovary are common in women, with about 80% being benign and occurring in the reproductive age group [23]. Ovarian tumours are multifaceted and their classification is based on the historical cell of origin [24, 25]. About 70-80% of primary ovarian tumours are epithelial in origin, 10% stromal and 5% germ cell, while the rest fall into other groups [26]. Dermoid cyst is one of the commonest ovarian tumours in child-bearing age [27], and 10% of

Generally, ovarian cysts that are painful may be as a result of torsion (Fig. 3), haemorrhage, rupture, be endometriotic or cancerous. Torsion of ovarian cyst commonly presents as severe

and pelvis, and abnormal growth in the lower genital tract should be sought for.

a specific follow up plan, which may indicate the need for further treatment.

**4. Severe pelvic pain**

38 Contemporary Gynecologic Practice

weight loss and cervical smear.

pain.

**5. Ovarian cysts**

cases are diagnosed during pregnancy [28].

Uterine leiomyomas or fibroids are benign tumours that arise from the myometrial smooth muscle fibres. They are the commonest tumours found in the human body. It is estimated that one-fifth of all women have one or more in the uterus at death [30]. Fibroids are present in 20-25% of women of reproductive age, commonly associated with nulliparity, and for some uncertain reasons are 3-9 times more common in blacks [30, 31]. Most uterine fibroids are symptomless but 35-50% of patients have symptoms [31], and these are dependent on their location, size, state of preservation and/ or degeneration, and whether or not the patient is pregnant.

Fibroids are usually not painful. Acute pain may arise under certain circumstances, such as torsion of pedunculated fibroids, degeneration (especially red degeneration), associated endometriosis/adenomyosis, and/or expulsion of pedunculated submucous fibroids through the cervix [32]. Fibroid also rarely causes acute pain when it outgrows its blood supply, thereby causing necrosis. Spasmodic dysmenorrhoea may result when expulsion of a pedunculated submucous fibroid stimulates uterine contraction [32]. Sarcomatous change, which occurs in 0.1-0.5% of cases [31], can result in pain as well. There is the need to look out for other comorbid conditions in cases of fibroids associated with pains.

With respect to the treatment of fibroids the factor considered in this section is the pain, therefore the patient has to be thoroughly evaluated; history, examination, and investigations. Pain is generally managed with the use of analgesics, ranging from acetaminophen (parace‐ tamol) to non-steroidal anti-inflammatory drugs and opioids. Definitive treatment would require surgery if analgesics alone, sometimes with antibiotics in cases associated with infection, fail to alleviate the symptoms. There is usually no room for use of medical treatment options for fibroids presenting with acute abdomen or severe pains.

Definitive surgical modalities for management of uterine fibroids include myomectomy, which leaves behind a functional uterus and thus preserving fertility, and hysterectomy, which is desirable for patients over 40 years of age and those not desirous of future fertility. Both procedures can be carried out via the abdominal route, vaginal route, or even laparoscopically. Hysteroscopic myomectomy is indicated for submucous fibroids complicated by abnormal bleeding with pain. Robotic surgery is employed in high technology medical facilities, especially in countries with advanced healthcare systems.
