Гінекологічні діагностичні дослідження та процедури

1. 1. Cole LA: The hCG assay or pregnancy test. Clin Chem Lab Med. 2012;50(4):617-630. doi:10.1515/CCLM.2011.808

Tests to evaluate for vaginitis include

• Vaginal pH: Tested with pH paper (normal vaginal pH is 3.8 to 4.2); increased [more alkaline] pH is found in bacterial vaginosis and trichomoniasis)

• Saline wet mount: Prepared with 0.9% sodium chloride; findings can indicate bacterial vaginosis (clue cells, polymorphonuclear leukocytes) or trichomoniasis (motile trichomonads)

• Potassium hydroxide (KOH) wet mount: Prepared with 10% potassium hydroxide; findings can indicate bacterial vaginosis (positive whiff test) or candidiasis (hyphae)

• Nucleic acid amplification testing (NAAT): Available for bacterial vaginosis, candidiasis, and trichomoniasis

Tests for sexually transmitted infections of the female genital tract include the following (see CDC: Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources):

• NAAT of a sample from the cervix, vagina, or urethra or a urine sample to test for certain local organisms (Trichomonas, Neisseria gonorrhoeae, Chlamydia trachomatis); sometimes, Gram stain and culture used for genital fluid samples

• Polymerase chain reaction (PCR), viral culture, or direct fluorescent antibody testing of a swab of lesions to test for genital herpes simplex virus infection

• Blood tests for systemic infections (HIV, hepatitis B or C, or syphilis)

Routine cervical cancer screening effectively detects preinvasive and early-stage disease and decreases cervical cancer incidence and mortality rates.

Two types of screening tests for cervical abnormalities are used:

• Tests for high-risk human papillomavirus (HPV) genotypes

• Pap test (cervical cytology)

Recommendations vary regarding the choice of screening test, frequency, and age to begin and discontinue screening (see table Cervical Cancer Screening). The American College of Obstetricians and Gynecologists (ACOG) follows the recommendations of the United States Preventive Services Task Force (USPSTF) (1, 2):

• 21 years: Begin cervical cancer screening

• 21 to 29 years: Cervical cytology every 3 years (alternatively, average-risk patients ≥ 25 years may begin screening with primary HPV testing alone every 5 years)

• ≥ 30 to 65 years: Cervical cytology alone every 3 years; or HPV test alone every 5 years; or cytology and HPV co-testing every 5 years

• > 65 years: Discontinue screening if patient has adequate negative screening for the prior 10 years; for women without documentation of prior screening, continued screening until criteria for stopping are met

For women with certain indications (eg, women who have HIV infection, are immunosuppressed, have previous abnormal cervical cancer screening results), more frequent screening may be required.

If patients have had a total hysterectomy (cervix and uterus removed) and have no history of cervical cancer or high-grade cervical intraepithelial neoplasia, further cervical cancer screening is not indicated.

Abnormal results of cervical cancer screening tests require further evaluation, as appropriate.

Diagnostic or treatment procedures of the cervix are performed if there are abnormal findings on pelvic examination, cervical cytology, or HPV testing. A cervical biopsy is also done if there is a grossly visible cervical lesion and the diagnosis is uncertain on examination.

Diagnostic procedures include

• Colposcopy: Examination of the vagina and cervix with a magnifying lens (eg, to identify areas that require biopsy)

• Cervical biopsy: Biopsy of cervix, usually taking a 1 to 2 mm specimen

• Endocervical curettage: Insertion of a curet to obtain tissue from inside the cervical canal

Cervical conization (cone biopsy) procedures can be used for diagnosis and/or treatment. These procedures remove a conical wedge of cervical tissue using different techniques including

• Loop electrical excision procedure (LEEP): Performed with a thin wire loop that conducts an electrical current

• Cold knife conization: Performed with a scalpel

• Laser conization: Performed with laser

Procedures used only for treatment include

• Cervical ablation: Techniques include cryotherapy, carbon dioxide therapy, thermal ablation, or diathermy

1. 1. American College of Obstetricians and Gynecologists: Updated cervical cancer screening guidelines. Published October 2016. Reaffirmed April 2023.

2. 2. US Preventive Services Task Force: Screening for Cervical Cancer: US Preventive Services Task Force recommendation statement. JAMA 320 (7):674–686, 2018. doi:10.1001/jama.2018.10897

Vulvar biopsies are indicated for patients with

• Symptoms or examination findings suggestive of vulvar intraepithelial neoplasia, vulvar malignancy (eg, squamous cell carcinoma, melanoma), or vulvar dermatoses (eg, lichen sclerosus, lichen planus)

• Any visible vulvar lesion for which a definitive diagnosis cannot be made on physical examination

• Lesions that did not respond fully to or recurred after medical treatment

• Lesions with an abnormal vascular pattern

• Lesions requiring definitive treatment by excisional procedures

Vulvar biopsy is an office procedure performed under local anesthesia (1 to 2% lidocaine), which is injected subdermally into the area to be biopsied. Often a 3- to 4-mm punch biopsy is performed, using a punch biopsy instrument. In some cases, a lesion is removed using a surgical scissor (eg, a small pedunculated lesion), an excisional biopsy is performed with a scalpel (eg, for wide local excision for vulvar neoplasia), or a shave biopsy (eg, for skin tags, warts) is done. Hemostasis is achieved using pressure, ferric subsulfate (Monsel) solution, or silver nitrate sticks. Occasionally a suture may be needed if bleeding persists or the biopsied area is large.

Relative contraindications to vulvar biopsy include bleeding diathesis and current anticoagulant therapy.

Vaginal biopsies are not commonly performed and are indicated when there is a concern for vaginal intraepithelial neoplasia or vaginal malignancy or when there are abnormal lesions that require pathology evaluation for diagnosis.

Vaginal biopsies are performed using a long punch biopsy instrument or a stitch and cut method (a stitch is placed into the suspected lesion or area and a pair of scissors is used to excise the lesion). Hemostasis is achieved by placing another stitch or by using ferric subsulfate (Monsel) solution or silver nitrate sticks.

Relative contraindications to vaginal biopsy include bleeding diathesis and current anticoagulant therapy.

Endometrial sampling may be done as an office endometrial biopsy procedure or as an operative procedure (dilation and curettage with or without hysteroscopy).

Indications for endometrial biopsy include (1)

• Postmenopausal uterine bleeding

• Abnormal uterine bleeding (AUB) in patients who are ≥ 45 years or < 45 years with endometrial cancer risk factors (eg, obesity, history of unopposed estrogen exposure), failed medical management, or persistent AUB

• Follow-up monitoring for endometrial hyperplasia

• Cervical cytology with glandular cells associated with an increased risk of endometrial cancer: benign-appearing endometrial cells in patients ≥ 45 years; atypical glandular cells [AGC]-endometrial; AGC or adenocarcinoma in-situ (AIS) in patients ≥ 35 or in those < 35 with endometrial cancer risk factors or symptoms; or persistent abnormal cervical cytology results in patients with any AGC category (2)

• Screening in patients at high risk for endometrial cancer (eg, Lynch syndrome)

The only absolute contraindication for endometrial biopsy is a desired intrauterine pregnancy. Relative contraindications are

• Bleeding diathesis or current anticoagulant therapy

• Acute infection of the vagina, cervix, uterus, or fallopian tubes

• Cervical stenosis

• Congenital female reproductive tract anomalies

An endometrial biopsy is usually performed as an office procedure. In some postmenopausal patients, cervical preparation with misoprostol (200 to 400 mcg vaginally or orally the night before the procedure) may help to dilate the cervix (3). Anesthesia is not required, but some clinicians advise patients to take preprocedure nonsteroidal anti-inflammatory drugs or offer patients a topical cervical anesthetic spray or paracervical block (4). Antibiotic prophylaxis is not required.

During the procedure, a thin (< 3 mm), flexible, disposable, plastic, low-pressure suction curette is inserted through the cervix to the level of the uterine fundus; mechanical dilation is not usually required. Usually, tenaculum is placed on the anterior cervix to stabilize the uterus. Suction is applied by withdrawing an internal plunger. To obtain an adequate sample of the endometrial cavity, the clinician turns the device 360° and moves it 3 times in a cephalic to caudal motion. Alternatively, for postmenopausal women, endometrial sampling with a brush device is more likely than a suction device to yield an adequate sample (5).

The most common adverse effects are uterine cramping or vasovagal reactions. Uterine perforation is a rare but more serious potential complication.

1. 1. Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012;120(1):197-206. doi:10.1097/AOG.0b013e318262e320

2. 2. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors [published correction appears in J Low Genit Tract Dis. 2020 Oct;24(4):427]. J Low Genit Tract Dis. 2020;24(2):102-131. doi:10.1097/LGT.0000000000000525

3. 3. Al-Fozan H, Firwana B, Al Kadri H, Hassan S, Tulandi T. Preoperative ripening of the cervix before operative hysteroscopy. Cochrane Database Syst Rev. 2015;(4):CD005998. Published 2015 Apr 23. doi:10.1002/14651858.CD005998.pub2

4. 4. Charoenkwan K, Nantasupha C. Methods of pain control during endometrial biopsy: A systematic review and meta-analysis of randomized controlled trials. J Obstet Gynaecol Res. 2020;46(1):9-30. doi:10.1111/jog.14152

5. 5. Williams AR, Brechin S, Porter AJ, et al: Factors affecting adequacy of Pipelle and Tao Brush endometrial sampling. BJOG. 2008;115(8):1028-1036. doi:10.1111/j.1471-0528.2008.01773.x

Dilation and curettage (D&C) involves dilation of the cervix and insertion of a curet to remove endometrial tissue, usually when endometrial hyperplasia or cancer is suspected. D&C is sometimes performed as a therapeutic procedure for abnormal uterine bleeding.

Hysteroscopy can be performed concurrently with D&C if visualization of the uterine cavity is required. After cervical dilation, a camera (hysteroscope) is inserted through the cervix into the uterine cavity. The cavity is inspected for abnormalities. Focal biopsies or myomectomy may then be done by passing instruments through a channel in the hysteroscope.

Laparoscopy is a transabdominal procedure during which small abdominal incisions are made. A camera (laparoscope) is inserted for inspection of the abdominal cavity or for surgical procedures. Diagnostic laparoscopy is performed when abnormalities cannot be adequately detected or evaluated with imaging studies (eg, endometriosis, complex ovarian cysts).

Culdocentesis, now rarely used, is needle puncture of the posterior vaginal fornix to obtain fluid from the cul-de-sac (which is posterior to the uterus) for culture and for tests to detect blood from a ruptured ectopic pregnancy or ovarian cyst.