INFORMATION FOR PATIENTS

Smears are taken as part of the cervical cancer screening programme to detect abnormality in a precancer stage, before it could turn into cervical cancer. Patients are referred to colposcopy if their smear comes back abnormal.

Colposcopy is a special speculum examination using a microscope to identify areas of abnormality. If the abnormality is mild, only observation is required, however if severe abnormality is detected then a treatment called loop excision (removal of the surface of the cervix) is required under local anaesthesia.

Recently, HPV-test has been incorporated in the management of patients with abnormal smear. This helps in identifying those patients who require special attention with their smear abnormalities.

Our clinic offers counselling on abnormal smear test and the full range of colposcopy services.

Cervical cancer is related to human papilloma virus (HPV) infection. If the cells of the cervix are infected by the high-risk type viruses, these infected cells can turn into precancer cells and later into cancer cells.

The cervical cancer screening test – smear – can pick up these changes well before the cells would turn into cancer and a small procedure called loop biopsy can remove these precancer cells.

Vaccination of young children against HPV is likely to further reduce the number of cervical cancers in future.

What are the symptoms of cervical cancer?

  • Persistent, profuse, foul smelling vaginal discharge
  • Irregular and post coital vaginal bleeding
  • Pelvic pain, leg swelling, urinary symptoms, tiredness
  • Often no symptoms develop in early stages

Although these symptoms are typical for patients with cervical cancer, many other benign gynaecological conditions can present with the same symptoms.

How is the diagnosis of cervical cancer made?
Patients with cervical cancer require specialist care by a Gynaecological Oncologist. The following tests are necessary when managing cervical cancer:

  • Careful gynaecological examination and cervical biopsy or loop excision
  • MRI-scan to see the exact size of tumour and whether the cancer has spread outside the cervix.

How can cervical cancer be treated?
Early stage cervical cancer can be treated with surgery which is usually a special hysterectomy called radical hysterectomy. This operation can be performed via keyholes or a tummy cut (laparotomy). Advanced cancer requires chemotherapy and radiotherapy.

What are the benefits of keyhole surgery?

  • Short (24-48 hours) hospital stay
  • Fast recovery back to normal life
  • Less postoperative pain
  • Better cosmetic outcome (minimal scarring of skin)

Can I preserve my fertility?
If the woman with cervical cancer wishes to preserve her fertility, fertility sparing surgery can be considered. Our team has great experience in managing patients with cervical cancer and can offer all type of surgical procedures.

  • Radical trachelectomy removes the cancer but leaves the uterus itself intact, which allows the patient to have a baby.
  • In our practice, this operation is performed via keyholes (laparoscopy).

Miss Singh and Mr Balega are nationally renowned experts in managing patients with cervical cancer and they provide the full range of diagnostics and treatment.

When do we need to remove the uterus?

In case of several benign and malignant conditions the removal of uterus with or without the ovaries is required:

Benign:

  • Endometriosis
  • Fibroids
  • Abnormal bleeding resistant to other treatment
  • Family risk of uterine cancer (prophylactic)

Malignant:

  • Cervical cancer
  • Uterine cancer
  • Ovarian cancer

How can the uterus be removed?

Most of the cases the uterus can be removed via keyhole surgery unless the size of the uterus is large. In our practice, the default position to hysterectomy is the total laparoscopic hysterectomy, which results in the best outcome. We only perform laparotomy (tummy cut) for patients with very large uterus.

What are the benefits of keyhole surgery?

  • Short hospital stay (24-48 hours)
  • Fast recovery back to normal life
  • Less postoperative pain
  • Less blood loss
  • Better cosmetic outcome (minimal scarring of skin)

What is the usual postoperative care after keyhole surgery?

  • Patients can drink and have light food a few hours after surgery
  • Patients do not usually require strong painkillers but paracetamol or ibuprofen only as there is only some mild pain
  • The bladder catheter comes out a few hours after operation
  • Patients can walk soon after surgery
  • Patients usually discharged within 24-48 hours
  • Patients usually resume their normal activity (working, driving, flying) within two weeks after surgery.

Endometriosis is a common cause for pelvic pain, painful intercourse and painful periods. It can also cause infertility. Endometriotic cells resemble the lining of the womb and usually lie outside the uterus and cover the pelvis.  It may also involve the ovary and form cysts called endometrioma. This is a hormone dependent condition and therefore gets exacerbated around the menstrual periods.

Treatment of endometriosis
Treatment and management is dependent upon the intensity of symptoms and its effect on the quality of life. Mild endometriosis if asymptomatic does not require any treatment. Endometriosis can both improve with time or progress and become severe with time if left without treatment. Endometriosis does however regress and improve after menopause as hormonal support is withdrawn. Treatment of endometriosis can be medical therapy or surgical treatment.

Medical therapy: oral contraceptive pills or other hormonal treatment such as GnRh therapy can suppress the ovarian function and the endometriosis too.

Surgical therapy: resection of endometriotic nodules can be used either before medical treatment or after an unsuccessful medical treatment.

The standard management for endometriosis is laparoscopic surgery – this is used both for diagnosis and treatment of endometriosis. Laparoscopic excision of endometriotic nodule, deposits, removal of endometriotic cysts can improve symptoms.

Occasionally patients have to undergo laparotomy (tummy cut) for complex endometriosis of the pelvis.

What is trachelectomy?
Trachelectomy is a fertility-preserving operation in the treatment of cervical cancer aimed at preserving the uterus in women who are desirous of future pregnancy. 

How can the fertility spared if there is a cancer in the cervix?
The cervix (neck of womb) is not an essential body part for pregnancy, although has got important roles. If the cancer is confined to the neck of the womb, removing the cancerous cervix only will allow the surgeon to preserve the body of the womb, where the baby can grow.

 How is this procedure performed?
This operation can be performed either via keyhole (laparoscopy) or vaginally or via a tummy cut (laparotomy).

Keyhole operation has got the advantage of short hospital stay (2 days), quicker recovery back to normal activities such as work, looking after children, flying (2-3 weeks).

Who can perform this operation?
This procedure can only be performed by specialist gynaecologists called gynaecological oncologists who are trained to perform cancer surgery.

Is trachelectomy a safe procedure?
Trachelectomy is a relatively new procedure but have been performed for more than a decade now worldwide in cancer centres. There is good evidence that in the hands of gynaecological oncologists, trachelectomy is a safe procedure from cancer point.

Is there any effect of trachelectomy on future pregnancies?
Trachelectomy can be associated with difficulty in conceiving because of cervical scarring and stenosis. If women conceive then there is a higher incidence of miscarriage and preterm birth.  All women after trachelectomy are advised against vaginal birth and should deliver via caesarean section.

Fibroids are benign growths in the muscle wall of the womb and are very frequent in women. Most fibroids cause no symptoms and therefore do not always require treatment.

Symptoms
The symptoms of fibroids are related to their size, site of location within the uterus and the number of fibroids. Fibroids can cause heavy and painful periods, infertility, pressure symptoms on the bladder or bowel resulting in urinary frequency or constipation.

Management
Small fibroids (<5cm) if not associated with any symptoms do not require any treatment. If a fibroid is large or causes symptoms, a consultation with a gynaecologist is required. Physical examination and imaging (ultrasound or MRI-scan) is necessary to assess the fibroid and to plan treatment.

Treatment
Treatment is related to the severity of symptoms, fertility goals and characteristics of the fibroids.

Hormonal treatments (GnRH) can shrink the fibroids but the effect is only temporary and therefore usually used prior to the surgical treatment.

Embolisation blocks the blood supply to the fibroids and can be introduced under radiological guidance. Popular method for women who are keen to avoid a hysterectomy and desperate to preserve their uterus.

Surgery
Myomectomy means the removal of the fibroids only with preserving the uterus itself. This can be done both laparoscopically and by open surgery depending upon the size of the fibroids. This is a treatment option for women who are considering conception in future.

Hysterectomy. This is permanent treatment for fibroids and reserved for large fibroids and in women who have completed their fertility goals.

Infection by human papilloma virus (HPV) is common amongst sexually active women and men but most of the times it does not cause any harm. There are different types of viruses causing different problems.

Low-risk HPV: they often cause warts on the skin of the vulva, vagina and the cervix, which can be sexually transmitted.

High-risk HPV: these viruses can be associated with precancer changes and have the potential to develop into cervical cancer.

 The HPV vaccination. The vaccination against HPV in schoolgirls was demonstrated to significantly reduce the HPV-related warts and is supposed to reduce the number of women with cervical cancer. There are two different types of vaccination, one is against two types of papilloma virus, while the other is against four types of papilloma virus. In the UK, all schoolgirls aged 11-13 years have the vaccination against the two types of virus for free.  The vaccination against the four types of virus is also available on prescription. The role of vaccination in sexually active women is unproven.

 Our clinic offers counselling on all HPV-related conditions.

Keyhole surgery (laparoscopy) uses small (5 to 10mm) cuts on the skin to introduce tiny instruments into the tummy. The same quality of operation can be performed via keyholes as in tummy cut operation (laparotomy) but the complications are much less. 

What are the benefits of keyhole surgery?

  • Short hospital stay (1-2 days)
  • Fast recovery back to normal life
  • Less postoperative pain
  • Better cosmetic outcome (minimal scarring of skin) 

What is the usual postoperative care after keyhole surgery?

  • Patients can drink and have light food a few hours after surgery
  • Patients do not usually require strong painkillers but paracetamol or ibuprofen only as there is only some mild pain
  • The bladder catheter comes out a few hours after operation
  • Patients can walk soon after surgery
  • Patients usually discharged within 24-48 hours
  • Patients usually resume their normal activity (working, driving, flying) within two weeks after surgery.

Miss Singh and Mr Balega are advanced level minimal invasive surgeons with extensive experience in gynaecological laparoscopic surgery. They mastered the keyhole technique to minimise complications and hospital stay allowing patients to quickly return to work and to their families.

What is laparoscopic radical hysterectomy?
Radical hysterectomy is the standard operation for early cervical cancer. It involves the removal of the cervix (neck of womb), the uterus (womb) along with the parametrium (tissue around cervix) and the upper 2cm of the vagina. The pelvic lymph glands are also removed. Preservation of the ovaries can be considered in premenopausal women. The procedure is performed via a few keyholes in the tummy.

What are the benefits?
Because of the smaller trauma to the skin and the tissues in the pelvis, recovery is much quicker after keyhole surgery than after a tummy cut (laparotomy). Average hospital stay after laparoscopic radical hysterectomy is 2 days only and patients resume their normal activity very quickly. That can be an important factor for those looking after their children, needed to go back to work and those who would like to enjoy their full, active life as soon as possible.

 The benefits of keyhole surgery are:

  • Shorter hospital day (2 days)
  • Faster recovery back to normal (2-3 weeks sick leave only)
  • Less blood loss during the operation
  • Less wound infection and breakdown
  • Better cosmetic results in the tummy

Who can perform this operation?
This procedure can only be performed by those specialist gynaecologists called gynaecological oncologists who are trained to perform advanced laparoscopic cancer surgery.

Ovarian cysts in premenopausal women are usually benign (non-cancerous) or borderline (neither benign nor cancerous) and usually cause symptoms but can also remain silent.

Ovarian cysts in postmenopausal women however require more vigilance as the risk of cancer is higher.

When do we need to remove ovarian cyst?
Not all ovarian cysts require an operation, however in the following conditions the surgical removal of ovarian cysts is required:

Premenopausal women:

  • Simple ovarian cysts which are persistent and are larger than 7 cm
  • Any cysts causing symptoms such as pelvic pain, pressure, painful intercourse
  • Cysts with worrying features for cancer on ultrasound scan
  • Positive blood test for tumour markers

Postmenopausal women:

  • Any persistent cyst larger than 5cm requires attention and frequently removal
  • Any suspicion for cancer or if the cyst causes symptoms

How can ovarian cysts be removed?

Ovarian cysts can be removed via keyhole surgery in majority of the cases unless there is a high risk for cancer or the size of the cyst is large. Your gynaecologist will calculate your risk based on blood test (tumour markers) and ultrasound findings. Should the calculation show high risk for cancer, the operation is usually done via a tummy cut (staging laparotomy) and can only be done by specialists called gynaecological oncologists.

Mr Balega and Miss Singh are trained in advanced laparoscopic surgery and are eminent gynaecological oncology surgeons. They provide expert services on all forms of ovarian cysts and can deliver the whole range of treatment options.

What is ovarian cancer surgery?
Ovarian cysts can be either benign or cancerous. All women with an ovarian cyst should undergo an ultrasound scan and blood test for tumour markers. The risk for cancer is then calculated by the gynaecologist. A CT-scan at that point may need to be performed. Women with ovarian cysts suspicious of cancer are referred to specialist gynaecologists called gynaecological oncologists.

Staging surgery
Women who completed their families are usually offered a total hysterectomy which includes the removal of the uterus, the ovaries and tubes. Biopsy from the fatty apron called omentum is also taken. This is to diagnose the cyst and if there is cancer to see if the cancer cells have spread.

Young women who wish to preserve their fertility need special consideration and expert opinion from a gynaecological oncologist.

Debulking surgery
Ovarian cancer often spreads elsewhere in the pelvis or in the abdomen. In this situation, surgically removing all disease is an essential part of the treatment. This special operation is called debulking surgery and includes a total hysterectomy (removal of womb, ovaries, tubes), the removal of the whole omentum, and cutting out all cancer nodules sitting in the tummy. Sometimes resection of a part of the bowels, removal of the spleen or parts of the diaphragm is required. Patients require additional chemotherapy after surgery to tackle the cancer.

What are the benefits of ovarian cancer surgery?
Studies showed that patients with ovarian cancer who had all their disease surgically removed had the best outcome. Surgery for suspicious ovarian cysts or debulking surgery for obvious cancer can only be performed by specialist gynaecologists called gynaecological oncologists. This improves outcome and reduces the risk for potential complications.

Mr Balega and Miss Singh have established a nationally renowned ovarian cancer team in Birmingham and have vast experience in managing patients with ovarian cancer. They are trained to perform complex (ultraradical) surgical procedures. Birmingham has excellent results in the management of ovarian cancer patients.

There are various causes for pelvic pain:

  • Pelvic infections (PID)
  • Endometriosis
  • Fibroids
  • Ovarian cysts
  • Adhesions
  • Not infrequently, no obvious cause is identified

 The management of pelvic pain often requires multidisciplinary approach involving gynaecologist, pain specialist, physiotherapist and psychotherapist. Different investigations are required to elucidate the cause of pelvic pain, such as swabs from vagina and cervix, ultrasound scan, MRI-scan. These investigations are non-invasive, but frequently unsuccessful to reveal the cause of pain.

Diagnostic laparoscopy remains an important test in diagnosing the cause of pelvic pain, such as endometriosis, adhesions.

Laparoscopic treatment of pelvic pain
Laparoscopy is effective in not only diagnosing but also treating endometriosis. Resection of endometriotic nodules, removal of endometriotic ovarian cysts are usually carried out laparoscopically. Ovarian cysts can also be removed laparoscopically. If adhesions found in the pelvis, they can be released which may diminish the pelvic pain.

Period problems are common in young women and often resolve spontaneously. Problems with menstrual period, which require medical attention are:

  • Irregular periods
  • Frequent, heavy periods
  • Infrequent (rare) periods
  • Bleeding between cycles
  • Pre- and postmenstrual spotting
  • Postcoital bleeding
  • Postmenopausal bleeding

Patient with the above period problems require a comprehensive gynaecological examination which may include an ultrasound scan. They may also need to undergo further investigations such as biopsy from the cervix or uterus, swabs from the vagina and cervix, blood tests for hormone levels.

Treatment of period problems depends on the underlying cause and the symptoms of the patients.

Any bleeding or spotting after menopause is abnormal and requires investigations. One if five women with postmenopausal bleeding has either cancer or precancer causing the symptoms. Other causes are atrophy (thin genital tissue due to lack of oestrogen) and benign polyps.

Clinical assessment by an expert gynaecologist and a pelvic ultrasound scan are required and it is very likely that a biopsy from the womb is needed. This can usually be done in the clinic but occasionally a procedure under general anaesthesia is required. If precancer or cancer is diagnosed, specialist opinion is advised.

Who requires risk-reducing surgery?
There are families in the UK who are at high risk for developing ovarian cancer. Unfortunately, studies confirmed that there is no effective screening method to detect ovarian cancer early enough and the only effective way to prevent this cancer is the surgical removal of the ovaries and tubes.

Rarely, uterine cancer (cancer of the womb) can also run in the family along with bowel cancer, prostate cancer, stomach cancer and ovarian cancer. This is called HNPCC-syndrome (hereditary non-polyposis colorectal cancer) or Lynch type 2 syndrome.

When should this operation done?
The timing needs to be carefully discussed with your gynaecologist. Factors considered are age, completion of family, age when cancer developed in other family members and BRCA mutation status.

What type of operation is required?
When ovarian cancer runs in the family or BRCA 1 or 2 mutation is detected, the removal of the ovaries along with the tubes is essential. Careful discussion about hormone replacement therapy needs to take place.

When you are at higher risk for uterine cancer, the uterus, cervix, ovaries and tubes all need to be removed (total hysterectomy).

How can risk-reducing surgery be performed?
Risk-reducing surgery is performed via keyhole surgery in majority of the cases.

Cancer of the uterus usually develops in postmenopausal women. Because of its symptoms, uterine cancer is usually detected in early stages and therefore has a good prognosis.

What are the symptoms of uterine cancer?
Postmenopausal vaginal bleeding or vaginal discharge are the most common presenting symptoms and therefore it is advised to visit a gynaecologist even you had only one episode of vaginal spotting.

In premenopausal women, irregular, heavy periods need investigation and cancer needs to be excluded.

How can uterine cancer be diagnosed?
Patients with postmenopausal bleeding should be urgently seen by a gynaecologist for an examination, a vaginal ultrasound scan and a biopsy from the uterus. This biopsy can usually be done as an outpatient procedure (Pipelle biopsy) but occasionally has to be performed under general anaesthesia (D&C). If endometrial cancer is confirmed on biopsy, an MRI-scan is to be performed to assess tumour spread within and outside the uterus.

What is the treatment for uterine cancer?
The standard management for uterine cancer is a total hysterectomy (removal of uterus, ovaries and tubes). Occasionally pelvic lymph nodes are also removed in suspected high-risk cases. Patients may require radiotherapy after the operation.

Our standard approach is a laparoscopic hysterectomy to facilitate quicker recovery with less complications.

What are the benefits of keyhole surgery?

  • Short (24-48 hours) hospital stay
  • Fast recovery back to normal life
  • Less postoperative pain
  • Less wound infections
  • Less blood loss
  • Better cosmetic outcome (minimal scarring of skin)

Thank you for booking an appointment with us. From here, we guarantee you that we provide you with the quickest care at the highest standards.

For your appointment with us, please get the followings:

  • Bring all your previous clinic letters and results with you
  • If you already had investigations, bring your images (CT, MRI) on a disc and your pathology slides/report, if possible
  • Bring a list of your current medications
  • Prepare your list of questions if you have any
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