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Review Article
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International Journal of Preventive Medicine, Vol 4, No 12, December, 2013 1347
Prevention of Diseases in Gynecology
Sebija Izetbegovic, Jasmin Alajbegovic1, Alma Mutevelic1, Almir Pasagic2, Izet Masic2
ABSTRACT
Background: Prevention of diseases in gynecology can be
improved by better understanding of health promotion and
management of diseases. Management is “the art of performing
jobs by or with other people” Mary Parker Follet.
Methods: A descriptive analysis was performed on scientific
studies in several published articles in medical journals and books.
Results: There are five primary functions of management as:
Anticipate and plan, organize, command, coordinate and control.
If we introduce the following definition in the sense of medical
science and apply it to the medical practice that would mean way
of recognizing, managing and resolving issues of diagnosis and
therapy of diseases (in this case gynecology diseases) according to
certain guidelines and treatment algorithms. Treatment of family
doctors is an important aspect in the quality‑of‑life of women and
their reproductive health as well as a significant issue in public,
environmental and social problems.
Conclusions: It is very important to deal with it on the primary
care level and in addition to promote the primary and secondary
prevention of diseases, which is sometimes more important than
the curative procedures. The primary prevention involves regular
gynecological examinations and screening. The doctors have also a
duty to educate women about the risk factors for malignant diseases,
as well as proposing some of the qualitative preventive measures.
Keywords: Diseases, gynecology, malignancies, prevention
INTRODUCTION
Management is “the art of performing jobs by or with other
people” Mary Parker Follet [Figure 1]. This is one of the many
definitions of management, but apart from these definitions, it
is very important to mention one of the general management
theory postulates that gave Henry Fayol and which proposed the
five primary functions of management as: Anticipate and plan,
organize, command, coordinate and control.
In the few last decades, papilloma and herpes viruses gets
more importance in the development of epithelial dysplasia,
neoplasia and cervix cancer. Cervix cancer has the second place
Department of Gynecology, Faculty of Medicine,
University of Sarajevo, Sarajevo, Bosnia and
Herzegovina, 1Faculty of Medicine, University
of Sarajevo, Sarajevo, Bosnia and Herzegovina
2Department of Family Medicine, Faculty of
Medicine, University of Sarajevo, Sarajevo, Bosnia
and Herzegovina
Correspondence to:
Prof. Izet Masić,
Department of Family Medicine, Faculty
of Medicine, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina.
E‑mail: izet.masic@gmail.com
Date of Submission: Jul 29, 2013
Date of Acceptance: Aug 1, 2013
How to cite this article: Izetbegovic S, Alajbegovic J,
Mutevelic A, Pasagic A, Masic I. Prevention of diseases
in gynecology. Int J Prev Med 2013;4:1347-58.
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013
1348
in mortality from gynecology diseases with the
incidence of 350,000 new cases diagnosed each
year.
In countries where screening is well‑developed,
such as England, the number of women suffering and
dying from cervix cancer has been reduced by 80%.
Breast cancer is the most common cancer among
women (about 32% of all cancers) and the most
common cause of death in the age of 45‑55 years. In
the world, about 1 million new cases are registered
each year. In developed countries, mortality was
significantly reduced to about 25%, thanks to the
early detection and modern therapy. The incidence
of the polycystic ovary syndrome (PCOS) is 15‑25%
in the population of women in the reproductive
age according to the European criteria. It is more
common in adolescents with 25%. Luckily, after
the age of 40 it is relieved by hyperandrogenemia
spontaneously so that in this age the incidence
is about 15% and in perimenopausal period the
incidence is 10%.
Diagnosis is made by medical history (general,
gynecologic, family), clinical examination (general
condition of the patient‑performance status and
gynecological speculum examination, bimanual
and rectal), by taking the smear by Papanicolaou
method and histological examination after biopsy.
Papanicolaou test is the standard test for cervix
cancer detection and like some results of several
studies shows this cytological test reduces the
incidence of cervix cancer in many countries.
Numerous studies have shown that the rate of
incidence and mortality are significantly reduced
where there is organized screening. The general
practitioners has an important role to make sure
that most of the women are attending regular,
systematic gynecological examinations according
to recommendation that exist in the national guide
for the prevention of malignant diseases.
In terms of medical science and practice this
imply: How to identify, lead and resolve, also
treat the diseases according to certain guidelines
and treatment algorithms. Furthermore, disease
management and compliance means algorithms
and the adoption of certain postulates by family
doctors in the health care centers as they represent
the first line of meeting and solving certain diseases
and conditions in patients.
Management of gynecological diseases
represents the application in the field of
gynecological diseases. Gynecological diseases are
diseases of the female genital organs and within
it we can talk about sexually transmitted diseases
and obstetrics.[1‑5] Their diagnosis and treatment
is an important aspect of the quality‑of‑life of
women and their reproductive health because
these diseases are public health and social problem
and is very important to deal with them at the
level of primary health‑care (PHC), so in this
context to promote both primary and secondary
prevention.[6,7] Sometimes, this is more important
than curative procedures. First of all, it is important
to promote a healthy life‑style and conscious
entering the sexual activity by young girls.
Primary prevention involves regular gynecological
examinations and screening. Screening involves
preventive examinations, which test apparently
healthy population with a preventive goal in order
to identify as early as possible those who show early
signs of disease or are at risk for the development
of a disease. In addition to primary prevention and
screening it is important to emphasize education
of patients about the importance of a healthy
life‑style and explaining hygienic and diet measures
for certain diseases. Thus, achieves the effect that
patients understand the importance of the early
of the prevention of gynecological diseases and
the application of regular screening for their early
detection in order to eradicate the disease.
Here, we will specify the definition and
epidemiology of the most frequent gynecological
diseases and their risk factors: Cervical cancer,
breast cancer, PCOS, irregular bleedings from the
uterus and vulvovaginitis.
Figure 1: Mary Parker Follet
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013 1349
In recent decades, to papilloma and herpes
viruses is attributed the growing importance in the
emergence of epithelial dysplasia, neoplasia and
cervical cancer. It is believed that the influence of
these viruses that penetrate the epithelium around
the outer cervix at the place of metaplasia of the
layered stratified epithelium in the cylinder caused
changes in epithelial cells that lead to dysplasia.
Cervical cancer primarily affects women from 45
to 50 years of age; approximately 37% of patients
are younger than 35 years. Women over 65 make
up 10% of patients and this age group usually dies
from the disease, which is related to progression of
the disease at the time of diagnosis.
Among gynecological malignancies cervical
cancer ranks second both in incidence and
mortality among women in almost all developed
countries, diagnosed each year. Although in
recent years their incidence declined, there are
still areas of high incidence of mortality among
women of low socio‑economic status, which is a
consequence of the lack or absence of regular and
irregular screening. In countries where screening
is well‑developed, such as England, the number of
women suffering and dying from cervical cancer
has been reduced by 80%. At 5‑year survival for
patients with early clinical stage varies from 50%
to 90% according to various prognostic factors.
Local recurrence is a significant cause of mortality.
Scientific evidences support the link between
human papilloma virus (HPV) infections which
is present in 93% of cases of cervical neoplasia.
The risk of malignant transformation in the
cervix increases with the presence of high‑risk
genital HPV subtypes. Among more than 70 so
far detected HPV virus types, most probable role
in oncogenesis have subtypes 16, 18, 31, 33 and
35. The disease often affects persons from lower
socio‑economic class, with a lower possibility of
regular health‑care. Early onset of sexual life and
a greater number of sexual partners, also favors
the development of the disease. Specifically,
the transformation zone in the younger age is
more sensitive to oncogenic agents. Smoking
is also a significant risk factor. The role of oral
contraceptives to date remains controversial.
Opinions are divided, but higher incidence of
abnormal histological types of cervical cancer is
observed in women who have for a longer period
of time used these contraceptives.
Breast cancer occurs and develops from the
milk ducts (duct epithelium) and lobule, so
the most common types are ductal (80%) and
lobular (10%) breast cancer. It can be in invasive
and non‑invasive form (ductal carcinoma in situ)
and (lobular carcinoma in situ). Breast cancer is
the most common cancer in women (about 32%
of all malignancies) and the most common cause
of death at the age of 45‑55 years. In the world
are registered each year about 1 million new cases.
In developed countries, mortality was significantly
reduced to about 25%, thanks to early detection
and modern therapy. Survival is slightly lower in
women younger than 40 years (82%), 40‑74 years
of age (88%) and at age of 75 years and over (89%).
Screening is the examination of women who have
no symptoms of the disease, with the purpose of
early detection of cancer. At these examinations,
the women are called for a review, which is repeated
at certain intervals. It is not known exactly what
causes the appearance of breast cancer, but it is
known that there are several risk factors, some of
which are already known from before; others are
yet to be explored. The frequency (incidence) of
breast cancer increases with age, about 80% occurs
after menopause. It is extremely rare before age of
20 years of age and is also unusual before age of
35 years.
Women who were previously treated for breast
cancer have 2 times greater risk of developing
cancer in the other breast. Among hereditary
factors often are mentioned the two breast cancer
genes: BRCA1 and BRCA2.
Few women in the course of their lives,
especially in the age of sexual maturity, did not
have an acute infection, subacute or chronic, at the
level of the external genitalia. Whether it comes
to an acute infection, recurrent from inactive focal
points or repeated infection (reinfection) is very
often health, family and social problem, as they
often have to be for long and persistently treated
and that the conservative and surgical therapy
eliminates its consequences or complications.
Vaginitis is an inflammation of the lining of the
vagina. Vulvitis is an inflammation of the vulva.
Vulvovaginitis is an inflammation of the vulva and
vagina. In these situations there is inflammation
of the tissues, which sometimes leads to vaginal
discharge. The causes are infection (Streptococcus,
Staphylococcus, Escheria coli, Neisseria gonorhea,
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013
1350
Chlamydia trachomatis, Trichomas vaginalis,
Mycoplasma hominis, also HPV, Cytomegalovirus,
etc.). Possible causes are also irritants in the form
of substances or objects, tumors or other abnormal
buildup of tissue, irradiation therapy, medications
and hormonal changes. Poor personal hygiene
can contribute to the proliferation of bacteria and
fungi and cause irritation. The feces can enter the
vagina through the abnormal connection with the
guts (fistula), which can lead to inflammation of
the vagina.
PCOS is the most common reproductive and
metabolic disorder in women of childbearing age,
which is characterized by chronic anovulation/
oligomenorrhea, hyperandrogenism and the
appearance of polycystic ovaries. Often is associated
with obesity, hyperlipidemia, insulin resistance (IR)
and type II diabetes. The incidence of the syndrome
is 15‑25% of the female population childbearing age
according to the European criteria for diagnosis.
It is somewhat more common in adolescents and
amounts to 25%. It is the lucky circumstance that
after the age of 40 it is spontaneously relieved by
hyperandrogenaemia and ovulation are more
common, so in this age its incidence is around 15%
and perimenopausal incidence is 10%. Because of
the many preceding pathophysiology changes of
PCOS it seems to affects very heterogeneous group
of patients. Despite the extensive literature data on
the etiology of PCOS, no uniform position on the
nomenclature and criteria used in the definition of
the syndrome exist. In 2003, it needed two of the
three criteria for the diagnosis of PCOS: Oligo/
anovulation, clinical or biochemical signs of elevated
androgens and polycystic ovaries demonstrated by
ultrasound (US). Furthermore, for the diagnosis
of PCOS it is necessary to exclude a number of
conditions and diseases related to similar changes
in the appearance of ovarian US image. Just the
appearance as polycystic ovaries is not sufficient
for the diagnosis of this syndrome. Diseases and
conditions that should be by differential diagnosis
excluded are hyperprolactinemia, gonadotropin,
congenital adrenal hyperplasia, Cushing’s syndrome,
virilizing tumors, hypothalamic amenorrhea,
acromegaly, hipertecosis, glucocorticoid and IR and
the effect of some medications. Childhood obesity,
especially in adolescence is the most important
trigger for the development and worsening of PCOS.
It was found that adolescent obesity independently
contributes to disorders at childbearing age, as well
as premature menarche, later infertility, infertility,
abnormal pregnancies and IR.
Any bleeding from the uterus that is
not regular menstruation is considered as
abnormal (metrorrhagia). Menorrhagia may result
from anatomical (visible pathological changes in
some of the genital organs) and functional reasons.
They may differ, not only in the time of occurrence,
duration, amount of the lost blood, but also at
intervals. It may be encountered during the entire
period of fertile age of the women. However, it is
significantly often seen at puberty and menopause, as
well as juvenile and menopausal bleeding (explained
by a disturbed balance in those ages between the
ovaries and other endocrine glands).
Causes of primary dysmenorrhea and
mechanism of pain occurrence in it are not known
today. It is believed that a substantial influence
have psychological factors, due to the threshold
of sensitivity of different people. More frequent
occurrence of dysmenorrhea is in underdeveloped
and physically weak parsons, who are suffering
from anemia, diabetes, tuberculosis and other
exhaustive diseases. For them to achieve good
therapeutic results it is necessary the healing and
repair of the general health condition. Among
etiological factors great attention is paid to the
factors that may lead to partial or complete
temporary obstruction. It is believed that the main
cause is hormonal imbalance between estrogen
and progesterone. The fact that dysmenorrhea
does not occur during anovulatory cycle, when the
endometrium is affected mainly by estrogen.
GOALS
The goals of this study were:
• Tounderstandtheroleof thehealthsystemin
early diagnosis of gynecological diseases
• Emphasize the importance of prevention
through the management of gynecological
diseases
• Highlight the role of family doctors in
educating women about the importance of
regular gynecological examinations.
METHODS
Made is a descriptive analysis of experience of
gynecological and obstetric diseases management
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013 1351
described in the articles published in indexed
journals retrieved from biomedical databases:
PubMed Central, ScopeMed, Google Scholar, etc.,
The authors of articles are mostly from the former
Yugoslavia. Emphasis is placed on the Guidelines
for gynecological diseases because they are basic
landmark that doctors should respect and use in the
management of any disease and also gynecological.
These are guides to whom physicians should adhere
and stick to them and their algorithms in the course
of their work. Within this set are: Basic symptoms,
how to identify and diagnose and therapy
protocols for the most common gynecological
diseases, as parameters to procedures in managing
gynecological and obstetric diseases.
MANAGEMENT OF COMMON
GYNECOLOGICAL DISEASES
For cervical cancer there are no early symptoms,
which will prompt the patients to contact a doctor
for review. Symptoms usually occur at a later stage
when it came to the erosion that accompanies
contact bleeding (bleeding is usually sparse and
occurs after intercourse, irrigation or gynecological
exam). They can be frequent and persistent, resistant
to therapy with concomitant blood secretion and in
advanced stage also with severe pain.
Diagnostic procedure includes: History
(general, gynecological, family, targeted family),
clinical examination (general patient state,
physical examination and gynecological speculum
examination, bimanual and rectal examination)
and swab by Papanicolaou method. The standard
Papanicolaou test for detection of cervical cancer
as the results of several studies indicated is
cytological test, which reduces the incidence of
cervical cancer in many countries. Papanicolaou
test has limitations such as low sensitivity and poor
reproducibility. Cytomorphologicall examination
of cervicovaginal smear is performed by “The
Bethesda system” classification: Atypical squamous
cell of undetermined sigificance (ASCUS), atypical
glandular cell of undetermined significance (AGUS),
low‑grade squamous intraepithelial lesions (LSIL) and
high‑grade squamous intraepithelial lesions (HGSIL)
and histopathological examination of the biopsies of
the cervix and cervical canal abrasion.
Additional tests, which are needed to determine
the stage of the disease, are: Cystoscopy,
rectoscopy, intravenous pyelography and chest
X‑ray. US, computed tomography, magnetic
resonance imaging (MRI) and abdominal
lymphangiography and possible laparoscopy
may not be used to determine the clinical stage
of disease according to International Federation
of Gynecology and Obstetrics (FIGO), but are
important in planning treatment. The clinical
stage of the disease is determined by using
the FIGO classification, which is also called
morphological classification because it is based
on tumor size and histological data for the early
stages and the spreading of pelvic masses with
disease progression [Figure 2].
Stage 0 ‑ Changes within the epithelium, or
preinvasive cancer (stroma intact).
Stage I ‑ The cancer is affected only cervix without
spreading to the body of the uterus.
•Ia1‑Stromal invasionbetween1and 3mm
with horizontal spread of up to 7 mm
•Ia2‑Invasionintothestromaof 3‑5mmfrom
the horizontal spread of up to 7 mm
•Ib1‑Clinicallyevidentcervicallesionsupto
4 cm in size
•Ib2 ‑ Clinical cervical lesions greater than
4 cm.
Stage II ‑ Expansion at the upper and middle third of
the vagina or parametrium (does not reach the bone).
•IIa1‑Initialexpansionintofornix
•IIa2 ‑ Spreading into the upper and middle
third of the vagina
•IIb1‑Initialinfiltrationofparametrium
•IIb2 ‑ Parametrium infiltration, but not
reaching the bone.
Figure 2: Colposcopy nding of the cervix cancer
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013
1352
Stage III ‑ Spread to the pelvic wall or lower third
of the vagina and/or hydronephrosis and/or
kidney dysfunction.
•IIIa ‑ Infiltration into lower third of the
vagina
•IIIb‑Tumor spread to thepelvicwall and/
or kidney hydronephrosis and/or kidney
dysfunction.
Stage IV ‑ Spreading outside of pelvis
•IVa‑Spreadintosurroundingorgans(bladder
or colon)
•IVb‑Distantmetastases.
After classification, according to the FIGO
classification and staging of disease, the decision
and the sequence of therapeutic procedures for each
patient individually, is made by a multidisciplinary
team of radiologists, pathologists, gynecologists,
radiation oncologists and medical oncologists.
Only a multidisciplinary approach to treatment
may result in properly and successfully treatment
and result in an overall improvement of survival.
Surgical therapy should be carried out in institutions
that have requirements for specified diagnostic and
multidisciplinary treatment planning. It should
aim to total removal of a diseased organ and
lymphadenectomy (minimum of 10 lymph nodes
from the chain of iliac blood vessels, both sides).
Adjuvant therapy should begin within a period of
3‑6 weeks after surgery or with advanced disease
immediately after the diagnosis and staging of the
disease. Concomitant chemo and radiotherapy
should be conducted in an institution that has
the technology for high voltage radiotherapy and
intra‑cavitary radiotherapy.
Self‑examination includes periodic examination
that the woman herself done by watching and feeling
the texture of the breast and axillary lodge. For this
review she should be taught by a doctor or nurse
of family medicine. Self‑examination should begin
at the age of 20 years. Previously advised monthly
self‑examination is abandoned in many developed
countries and is left to women to choose whether to
use it and in what interval and then follows clinical
examination. This includes physical examination
by a physician. Doctor carefully observe the breast,
their environment and with palpation explores
possible changes in the breast and adjacent lymph
nodes. Clinical examination should be conducted
at least once every three years for all women who
do not belong to a risk group, aged 20‑40 years.
From the age of 40 a woman should once a year
have clinical examination and then to perform the
initial (basic) mammographs. It is best that clinical
examination precedes mammography. If there is
a screening program, it in some countries starting
with the age of 40, in some at age of 45 or 50 years,
to age of 65 or 70 years, depending upon the
incidence of cancer, the available resources and the
level of population health culture. Mammography
is the “gold standard” of breast cancer diagnosis
and the most important screening method.
Mammography is a radiological imaging
method for breast that uses minimal radiation dose
and allows you to see the internal structure of the
breast. It is very important that the doctor discussed
with the woman and advise her about the best time
for her regular mammogram control in accordance
with the existing guide for screening, so it does
not happened that in the meantime the tumor that
was not visible progresses. Mammography as a
diagnostic tool has a much lower value (reliability) in
younger (premenopausal) women due to developed
glandular breast tissue that makes it radiologically
“dens” or poorly visible for interpretation. In these
cases, necessary are additional methods, US and
where possible, MRI.
US is an additional (complementary) method
for diagnosis using US waves, without ionizing
radiation, it is completely harmless and can be used
indefinitely even in pregnant women. It is used in
finding tumors in the dens breasts, for example in
young premenopausal women. MRI is a modern,
complementary method. Not a method for mass
screening, but in recent years can be used for the
diagnosis of tumors in genetically predisposed
women, where the screening normally begins in
early premenopausal period, then in case of more
dense breast tissue. When the radiologist in the
mammography images finds a change that raises
doubts on cancer, or is not able to declare it a
benign, it is necessary to take a small sample of
cells from the area for cytological examination and
setting cytological diagnosis. Before treatment the
set diagnosis of cancer, allows the duly treatment
plan, selection of the best method for treatment (for
example, type of surgery) in consultation between
the patient and team of specialists who will treat.
Although breast cancer is a very serious disease, it
can be successfully treated if detected at an early
stage, when it is not invasive and when tumor cells do
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013 1353
not have the ability for displacement‑metastasizing.
This treatment can be successful if it is carried out
by an expert team of specialists comprising of:
A surgeon, radiation oncologist, internist‑medical
oncologist, radiologist, pathologist, oncology
nurse, social worker and others as needed. This
expert team examines the patient at one place,
within joint review and makes decisions on any
additional diagnostic tests, treatment method and
sequence of methods.
In this way, each patient gets the best possible
treatment. If the cancer has not metastasized and
if not locally advanced, treatment usually begins
with the surgical procedure. If the tumor is small,
only the tumor can be removed and part of the
surrounding healthy breast tissue (sparing surgery)
so that the breast is not removed. At the same time
will be removed a number of lymph nodes from
the armpit. In some cases, it will be necessary to
perform radical surgery. After radical surgery plastic
reconstructive surgery may follow to make a new
breast, immediately during breast removal, or when
all other therapies are completed. After this surgery
irradiation treatment is carried out. Irradiation
therapy last for about 6 weeks and usually does not
cause special problems.
With the presence of a vulvitis of any etiology,
the patient complains of itching and burning
sensation and burning of the skin around the
vulva and vaginal introitus. On examination the
vulvar skin is bright red, easily swollen, painful
and warmer than surrounding tissue. First signs
of infection are redness and smaller island of the
affected areas of skin. Symptoms include a feeling
of itching, burning or light pain. Condyloma are
warty growths that occur as a consequence of
infection by Papova virus (from a group of HPV
type 6 and type 11), first individually around
vaginal introitus, usually at first in the area of the
perineum and later spread to most of the vulvar
skin, mucous membrane of the vagina and cervix.
Usually transmitted by sexual intercourse and
formed over a period of few days to months after
infection. Individual condyloma is bright red colors
on the stalk or tapered at the top. Later, they can
multiply to form a broad plate of compressed and
joined individual warts.
Diagnosis is made based on history (general,
gynecological, family, targeted family), clinical
examination (general condition of the patient,
physical examination and gynecological speculum
examination, bimanual and rectal examination) as
well as histological examination of taken biopsy
material. If the cause is the infection, the treatment
consists of antibiotic, anti‑fungal or antiviral
medications, depending on the agent.
If the infection is cured, to maintain the
improved condition can be used for a short time
rinsing of the vagina by exact ratio of vinegar and
water. Frequent washing and use of medical type
detergents is not advisable because it increases the
risk of developing pelvic inflammatory disease.
With antibiotics, treatment of bacterial infections
may include propionic acid gel that makes more
acidic vaginal mucus, which hinders the growth of
bacteria. In case of STDs both partners must be
treated simultaneously to prevent re‑infection.
Thinning of the lining of the vagina after
menopause is treated with estrogen supplements.
Estrogen can be administered orally or by skin
patch, or it can be applied directly to the vulva and
vagina. Additional procedures include wearing
comfortable and absorbent lingerie that allows
air to circulate, such as cotton or cotton padded
panties and maintaining the hygiene of the
vulva. It is needed to use glycerin soap because
other soaps can irritate this area. Sometimes,
putting ice on the vagina, sitting in cold baths or
cold compresses can ease sensitivity and itching.
Itching that is not caused by infection can be
mitigated by corticosteroid creams and ointments,
such as those that contain hydrocortisone, as
well as antihistamines taken orally. If chronic
vulvitis is caused by poor personal hygiene, the
first to be given is instructions on proper hygiene.
Following are some guidelines for the treatment of
vulvovaginitis caused by different agents [Table 1].
The diagnosis of PCOS is based on the case
history and physical examination, biochemical
tests and US examination of the ovaries.
There are a number of data from medical history
and physical findings that help in the diagnosis of
PCOS.
In the family history are important diabetes,
hyperandrogenaemia and clinical signs of
hyperandrogenism, subfertility. In personal history
is important birth weight, rapid weight gain in
infancy, rapid growth and early adrenarhe, obesity
in childhood and adolescence, menarche, menstrual
cycle characteristics, weight changes, symptoms
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013
1354
of hyperandrogenism, infertility and miscarriages.
Physical examination includes determination
of body mass index, the ratio of waist and hip
circumferences, blood pressure measurement
and evaluation of hyperandrogenism. Signs of
hyperandrogenaemia and hyperandrogenism,
which involves increased activity of androgens,
are seborrhea, oily skin and hair, acne, hirsutism,
alopecia and virilization. Hirsutism should be
distinguished from hypertrichosis in which there is
no male‑type hair distribution and is not dependent
on androgens.
However, the most common disorder in PCOS
is anovulation in more than 90% of women, which
is primarily linked with oligomenorrhea and rarely
amenorrhea. Anovulation is often associated with
irregular dysfunctional uterine bleeding.
US examination of the ovaries is unavoidable
and simplest method in the diagnosis of PCOS.
Criteria for declaring polycystic ovary according
to the latest classification are 12 or more follicles
with a diameter of 2‑9 mm and ovarian volume
greater than 10 ml and it is enough that only one
ovary have these characteristics. It is important
to emphasize that in puberty and adolescence US
PCOS is not specific.
Biochemical analysis includes determining
hormonal status: Follicle‑stimulating hormone,
luteinizing hormone, E2, total testosterone,
SHBG, free testosterone, dehydroepiandrostendion
sulfate, 17‑hydroxyprogesterone androstenedione,
the determination of IR (glucose tolerance test),
fasting glucose, IR and some dynamic tests are
performed exceptionally for the differential
diagnosis of PCOS with other endocrine disorders.
However, biochemical tests are necessary for girls
who are overweight, with pronounced hirsutism
or acne resistant to treatment. Furthermore,
to adolescents that in the first two years after
menarche have amenorrhea/oligomenorrhea
or repeated dysfunctional uterine bleeding is
necessary to determine the biochemical status.
Regardless of that, women with PCOS should be
treated and monitored continuously. Treatment of
PCOS depends on the patient’s age, symptoms and
signs of this syndrome and reproductive desires.
For this purpose, the hormonal preparations,
insulin‑sensitizing medicines and surgical
treatments are performed.
In adolescents with PCOS treatment is aimed
at controlling irregular bleeding, reduce acne
and hirsutism and reduction of obesity and
IR (risk of endometrial cancer in these women
is three times increased). The strongest effect of
anti‑androgens has oral hormonal contraceptives.
From other hormone therapy for PCOS should
be noted neandrogene progestogens that are given
because of their opposed action to estrogens
primarily to protect the endometrium. Surgical
treatment of PCOS is laparoscopic ovarian
electrocoagulation (drilling), which destroys fat
ovarian stroma.
Diagnosis is based on the history of irregular
bleeding and more abundant bleeding, the
existence of secondary anemia that accompanies it
and normal palpation findings of patient’s genital
organs, but if this is the result of anatomical changes,
then we cannot talk about these types of bleeding.
Therefore, it is essential that before diagnosis
are excluded other possible causes of irregular
bleeding, which is usually done by combined
rectal‑vaginal examination. Also, examination
of peripheral blood and bone marrow needle
aspiration is needed to exclude blood diseases.
Diagnostic curettage is performed in the extreme
conditions and can be therapeutic and most often
Table 1: The usual treatment of infection of the vagina and
vulva
Infection type Treatment
Candida caused
infection
Miconasol, clotrimasol, butoconasol
or terconasol (in a form of gel, vaginal
tablets or vaginal suppository);
uconazole or ketoconazole (orally)
Bacterial
infection
Usually metronidazole or
clindamycin (in form of vaginal
gel) or metronidazole orally; if
the cause is gonococci usually
ceftriaxone intramuscular injections)
with orally doxycycline
Chlamydia
caused infection
Doxycycline or azithromycin orally
Trihomonas
vaginalis
caused infection
Metronidazom orally
Humane
papilloma virus
infection
Three chlorine vinegar acid (directly
to condyloma); liquid nitrogen or
uorouracil (directly to condyloma)
in case of severe infections
Herpes virus
infection
Acyclovir orally or in a form of gel
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International Journal of Preventive Medicine, Vol 4, No 12, December, 2013 1355
the material is sent for histological evaluation.
Treatment of juvenile bleeding should first stop
the bleeding, compensate for lost blood and fluid
and improve the general condition. Among drugs
are given uterotonic agents and preparations of the
anterior pituitary lobe or synthetic preparations
with identical actions, together with calcium,
vitamin K and nicotinic acid amide.
Treatment of metrorrhagia in the generative
period is implemented by giving progesterone at a
dose of 25 mg and in the second half of treatment,
during the 3 months. If the therapy begins at the
stage of irregular bleeding, then progesterone
provides 2 or 3 days to regulate the bleeding. Patients
with atrophic endometrium and demonstrated lack
of estrogen are treated by alternately application
of estrogen and progesterone in 3‑4 cycles.
DISCUSSION
Quality and successful management of
gynecological diseases cannot be ensured without
following certain guidelines recommended by
experts in this field. Good clinical practice concept
that is applied in the world puts in front: (a) Patient
education, (b) counseling patients about healthy
life‑style, (c) conducting screening. Necessary and
advisable is to follow proper quality parameters
of provided gynecological care at certain levels
of its organization in the health system given in
the documents of the World Health Organization
and the comparable results (incidence, morbidity,
mortality) in the countries that did so in relation
to the countries that were not able to implement it.
Reasons for the latter may be low socioeconomic
status, lack of education of patients by their
physicians about the importance of regular
gynecological examinations, etc.
Although in recent years, the incidence of
cervical cancer has decreased there is still a high
incidence and high mortality among women with
low socio‑economic status, which is the result of a
lack of screening or irregular screening.
Numerous studies have shown that the rate of
morbidity and mortality are significantly reduced
where there is organized screening. Selected
family doctor plays an important role in regular
referring of woman to systematic gynecological
examinations according to the recommendations
that are in the National Guide for the prevention
of malignant diseases. Furthermore, he/she has a
duty to educate women about the risk factors for
malignant diseases, as well as preventive measures
to prevent their occurrence. In developed countries
where screening is regularly conducted the number
of women suffering and dying from cervical
cancer has been reduced by 80%. The disease often
affects women from lower socio‑economic class,
with a lower possibility of regular health care. In
developed countries, mortality was significantly
reduced to about 25%, thanks to early detection
and modern therapy.
Hence, it is very important to perform
comparisons on the basis of the results obtained
from the rich countries to the results from poor
countries because the incidence of diseases and
mortality rates are significantly higher in poor
countries than in rich ones. Poorer countries due
to lack of funds do not have good technological
methods for screening that will allow the disease
detection at an early stage and thus prevent
complications, which does not even have close
PHC centers and specialist consultation services
in their place of residence. Not only the financial
aspect is cited as an important factor in health
for an increase of morbidity and mortality in
a group of gynecological diseases, but there
are also important other factors, such as: (Un)
healthy environment, lack of clean drinking water,
inhumane living conditions, which may lead to
the occurrence of a number of infections than in
rich countries with higher gross national income
of the population in which they can provide a
means for personal hygiene. Richer countries have
the resources to invest in a variety of methods of
prevention, such as the development of educational
advertisements, posters and brochures for health
promotion and education of the population at all
levels: Local communities, schools, companies,
medical facilities, etc.
It is also very important to stress the importance
of sexual education, especially in schools, which can
contribute to reduced incidence of sexually transmitted
diseases, especially human immunodeficiency
virus (HIV) and the HPV which is considered as
important in the development of dysplasia with
consequential occurrence of cervical cancer.
Because of the high incidence of cervical cancer
it is necessary to organize a screening examination
of women. Numerous studies have shown that the
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013
1356
rate of morbidity and mortality significantly reduced
where there is organized screening. Selected family
doctor has a very important role in referring to regular
systematic gynecological examinations according to
the recommendations that are in the National Guide
for the prevention of malignant diseases. Furthermore,
the physician has a duty to educate women about the
risk factors for malignant diseases, as well as preventive
measures. Cervical cancer is an ideal disease for
screening because it typically has a long preclinical
phase, which allows early detection. Taking a cervical
smear and staining by method of Papanikolaou is
the best method available to reduce the morbidity
and mortality of invasive cancer of the uterus cervix.
According to the recommendations the screening
should begin as early as at the age of 18 years (or from
the moment of sexual relations start) because the age
of this disease occurrence moves toward the younger
generations. Control Papa test should be done once a
year and if two consecutive findings are negative then
is recommended control every 2 years. Any patient
with persistent or progressive cervical intraepithelial
neoplasia regardless of age, according to new studies
and each patient aged over 30 years should do HPV
deoxyribonucleic acid screening test. Regular and
proper implementation of the screening program is
also the best way to prevent the appearance of clinical
symptoms.
Outside the organized screening program,
women should be advised on the following:
• It is necessary to improve information and
increase awareness about the importance
of women about the possibilities and the
importance of preventive measures and
examinations
• Mammography is recommended to start at
age of 40 year and continue each year until a
woman is in good health
• Clinical breast examination as part of a
periodic health examination every 3 years for
women aged 20‑40 years, then every year
• Women should know how their breasts look
normal and that any changes immediately
and without delay leads them to the doctor.
Self‑examination is an option (according to the
will of women) and it should begin at the age
of 20 years
• Women at increased risk (family history,
genetic predisposition, previous cancer in the
other breast) should talk with their doctor about
the possible consequences of the irregular
examinations.
Screening as an organized program of secondary
prevention for breast cancer usually starts at the
age of 45 in women who do not belong to the risk
group of the first category and in high‑risk even
earlier, i.e. 40 years.
• Itisneeded toraiseself‑awarenessof women
by education from physicians and polyvalent
nurses.
It is necessary to create awareness among medical
staff in PHC, particularly family doctor about the
possibilities, needs and the importance of early
detection of breast cancer.
• It is necessary to provide human and
material resources to carry out the screening,
especially mammography machines, radiology
technicians and radiologists trained to perform
quality interpretation of the findings.
Establish centers at the secondary or tertiary
health‑care level for the setting of explicit diagnosis
and treatment of breast cancer.
• Create conditions for exact and timely
histopathological examination of biopsy
material at the secondary or tertiary health‑care
level.
A particular problem is the issue of taboo
in our society about sexuality, which is of a
systemic character and it should be a deal with
by the multi‑disciplinary teams in health care and
education (educators at all levels of education,
teachers, psychologists, sociologists, family
doctors, gynecologists, sexologists etc.). Our
society is patriarchal and this issue is becoming
a burning issue. The system should ensure the
introduction of the health education in primary
and secondary schools in the framework of
which the students, as age‑appropriate, are
informed about sexually transmitted diseases,
their prevention, diagnosis, treatment. The
particular attention should be paid to the
prevention of teenage pregnancies and abortions,
which is increasingly prevalent among younger
people with a tendency to move toward even
younger ages. Of course, the parents had to be
maximally involved in the work of these teams.
A particular problem is the social network that
indiscriminately provides information to young
people about sexuality, very often wrong and
non‑selective, even to say in an inappropriate
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013 1357
way that should be banned by the relevant
institutions. Unwanted pregnancy, HIV infection,
genital organs, especially sexually transmitted
disease are difficult to manage, especially their
early discovering and then treatment, which has
resulted in increasing incidence of unwanted
pregnancies, abortions and infertility in women,
or in women of childbearing age. Family doctors
and gynecologists here can play a key role,
especially in the field of health promotion.
CONCLUSION
Prevention of diseases in gynecology can
be improved by better understanding of health
promotion and management of diseases. The
importance of family medicine physicians and
their team is remarkable in the prevention of
gynecological diseases. Girls and women in their
office should find advice and a create way to
educate them about the importance of personal
hygiene, life‑style, diet and of course, sexual
behavior and the use of antibiotics that lead
to the disruption of normal vaginal flora and
fungal infections. They need to provide sufficient
information, either orally or by educational
brochures about the origin, prevention and
the ultimate treatment of these infections. To
girls and women should be emphasized that by
unprotected sex can infection can be transmitted.
Essential is also the education of those people
who do not have permanent sexual partner in the
proper use of condoms and before this would be
better the importance of highlighting the hazards
of promiscuity.
In the existing clinical guidelines for PCOS
is emphasized the need for early detection of the
syndrome. During compulsory education all school
children are available for preventive activities
and medical examinations, which provide great
opportunities for early detection and improving
the health of children and young people and in
the long‑term of the whole population. It is not
negligible also the economic effect. School medicine
has prepared guidelines with instructions and set of
activities and measures. Very often from the school,
doctor and nurse while working on counseling the
students and their parents seeking clarification on
the recommended procedures and treatment.
However, the first measure is a healthy life‑style and
weight reduction of obese patients. Thus, the weight
loss in combination with other therapeutic procedures
achieves optimal therapeutic effects, prevents
long‑term adverse and harmful effects and provides
high‑quality life. Early detection and timely treatment
can, not only reduce and eliminate these symptoms
and clinical manifestations, but also prevent the
development of diabetes and cardiovascular diseases
and some form of cancers later in life.
Family doctor in the health‑care system
should be oriented to a number of measures and
activities in order to adequately and well manage
gynecological disease in practice as follows:
• Knowthattheregularandproperimplementation
of screening programs at the same time is the
best prevention of the occurrence of clinical
forms of the disease
• Emphasizethat theincrease inthe numberof
patients in the early stages of the disease (based
on records and hospital records) is very
important
• Encouragetheimprovementof treatment(based
on hospital records and records of mortality)
• Highlightthe importanceofself‑examination,
to the extent that the woman be aware of her
breasts and to think of them, to be properly
informed
• Insist on teaching women, as well as the
professional staff in primary and family
health‑care, that breast cancer is very serious
disease, that early detection is important for
successful treatment and that the methods by
which breast cancer is detected is simple and
painless
• Counseling,educationandguidancetowomen
through a PHC about the importance of keeping
proper daily personal hygiene should be the
primary task of the family medicine teams
• Counselingandeducationof women,especially
young women of the dangers from frequent
change of sexual partners and condom use
should be encouraged by doctors
• Infection control, because they are a serious
social and public health problem, especially in
women who plan their families and pregnant
women, should also be stimulated
• Education of women about healthy life‑style
and proper nutrition, with weight reduction in
obese patients is one of the main tasks of the
family medicine teams
Izetbegovic, et al.: Prevention of diseases in gynecology
International Journal of Preventive Medicine, Vol 4, No 12, December, 2013
1358
• Emphasize the need for all school children
to undergo preventive activities and medical
examinations, which provides great o pportunities
for early detection and improving the health of
children and young people and in the long‑term
of the whole population
• Emphasize the need for the development of
guidelines with instructions and procedures for
the management of gynecological diseases.
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Source of Support: Nil, Conict of Interest: None declared.
