Gynaecological conditions

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Nearly every woman in the UK will suffer from a gynaecological condition at some time in her life. Lea Taylor looks at some of the most common problems

A common disclosure seen by underwriters on application forms is gynaecological disorders. Nearly every woman in the UK will at some time in their life suffer from a gynaecological problem. Although not necessarily life-threatening, these disorders can severely impinge not only on the quality of life but the ability to do everyday things. Excluding cancer, a few are explained below:

Abnormal cervical smears: With cancer of the cervix, the most common tumour found in women, regular screening is carried out to identify any dysplasia (abnormal tissue).

Not all abnormal smear results require specialist treatment, however they will need following up. The classification of cervical abnormalities is measured by cervical intraepithelial neoplasia (CIN). CIN I and II represent mild and moderate dysplasia. CIN III is severe dysplasia and indicative of a pre-cancerous condition. Further assessment can be made by colposcopy or biopsy, depending on the CIN classification.

Most cases are easily treated and patients are normally asked to attend regular follow-ups, depending on the severity.

Endometriosis: This can be a common problem and it is estimated that 10% of women during their reproductive years are affected. This condition is normally diagnosed between the ages of 25-35. However, it is believed that symptoms begin when regular menstruation starts. Family history of this condition, in a first-degree relative, increases the risk of developing the condition sixfold.

The cause of endometriosis is unknown. The condition involves the endometrium, the tissue that normally lines the uterus, growing in other areas of the body causing pain, irregular bleeding and often infertility. Ovarian blood cysts can develop, which are commonly known as chocolate cysts due to the collected blood darkening in colour.

Pelvic examination and laparoscopy are the diagnostic tools used to diagnosis endometriosis. The treatment can vary depending on the severity of the condition, the extent of the disease and the woman's desire to have children. It is estimated that 30-40% of women with endometriosis are infertile. Surgery is usually reserved for severe cases, with analgesics and hormone treatment used in most instances.

Ovarian cysts/polycystic ovary syndrome (PCOS):Most ovarian cysts are classed as functional cysts and normally disappear within 60 days. These develop around ovulation, where fluid released during this process is not reabsorbed, but instead forms a cyst. A pelvic examination or CT scan can identify the cysts. Where cysts are larger than 6cm or persist for longer than six weeks, a laparoscopy or surgical removal is normally carried out.

PCOS is a hormonal condition where the ovaries are enlarged due to multiple cysts. It affects around 33% of women in the UK.

This condition presents with irregular menses (periods), weight gain, insulin resistance and hirsutism (unwanted hair growth). Women are normally diagnosed between the ages of 20 and 30.

Family history can play a part and women diagnosed with PCOS often find their mother or sister also has the condition or similar symptoms.

Pelvic inflammatory disease (PID) - This is most common in women under 25, with 80% of cases transmitted sexually. PID can also follow childbirth or a gynaecological procedure such as the insertion of the coil or a dilatation and curettage (D&C). The term PID is usually used to describe infection of the pelvic region. This includes areas such as the fallopian tubes, ovaries and uterus.

Symptoms of PID include vaginal discharge, fever, painful sexual intercourse and irregular menstrual bleeding. In some cases, no symptoms are experienced. Some women who have an ectopic pregnancy (where the embryo implants in the fallopian tube) or infertility are often found to have so-called "silent PID", caused usually by chlamydia.

The majority of cases are treated with antibiotics. 20% of sufferers experience recurrence of this condition and the risk of an ectopic pregnancy increases to one in 20 compared with one in 200. After having PID, the risk of infertility risk increases significantly, with 15% risk of infertility following one episode of PID, 30% risk after two episodes and a 50% increase after three episodes of PID.

Prevention is simple - sexually active women are recommended to follow safer sexual behaviour and to have regular sexually transmitted disease (STD) screenings. Also, they are advised to seek immediate treatment of any exposure to a STD, which should include the treatment of partners.

Fibroids - These are benign smooth muscle tumours of the uterus. Fibroids have minimal malignant potential but may grow to an enormous size. This in turn poses problems should the patient become pregnant. Most woman are able to carry their babies to full term. However, on occasion some babies require early delivery due to lack of room in the uterus.

Fibroids do not usually interfere with fertility. However, they can block the fallopian tube or prevent the fertilized egg from implanting in the uterus lining.

The growth of the fibroid seems to depend on oestrogen stimulation, so fibroids are less common in women younger than 20 and post-menopausal women. Fibroids continue to grow as long as the woman is menstruating.

These are the most common pelvic tumour and can be present in 15-20% of reproductive aged women and 30-40% of woman aged over 30. Fibroids occur three to nine times more frequently in African-American women than Caucasian women.

Symptoms include feelings of pressure within the lower abdomen with pelvic pain and heavy periods. Often there are no symptoms. Treatment depends on the severity of the symptoms, age and future plans for having children.

Most fibroids can be monitored by pelvic examinations or ultrasounds. However, in some cases a pelvic laparoscopy may be necessary to rule out malignancy.

Hormonal treatment can also be used, tricking the body into thinking it is in a menopausal state. Treatment can last for a few months, during which the fibroids will shrink due to oestrogen reduction. Unfortunately, once the treatment stops the fibroid will start to grow again.

Menstrual disorders - These consist of dysmenorrhoea, menorrhagia/metrorrhagia and amenorrhoea/oligomenorrhoea.

Dysmenorrhoea - also known as painful periods - can occur on a regular (monthly) basis and can be similar to mini labour pains. This condition can severely affect women to the extent of causing time off work. The pain is caused by strong contractions of the womb and the opening of the neck of the cervix. Having a baby almost always cures this condition.

Menorrhagia/Metrorrhagia - every woman's menstrual cycle is different. However, on average most menstrual cycles occur on or around every 28 days and last between four and seven days. Flow lasting more than seven days is classed as menorrhagia (excessive bleeding) and may require investigation.

Anaemia can be a result of menorrhagia and also any underlying blood clotting conditions have to be ruled out.

Metrorrhagia (bleeding between periods) - this condition requires further investigation especially in post menopausal women and women over 50, as the malignancy risk is higher.

Common causes include fibroids or polyps in the uterus, fluctuation in hormone levels, using the contraceptive pill, abortions or ectopic pregnancies. Diagnostic tests may be performed such as cervical smear/STD screening, blood tests to check hormone levels and a pelvic ultrasound.

Amenorrhoea/oligomenorrhoea - the absence of periods is known as amenorrhoea and the term used for infrequent or irregular periods is oligomenorrhoea.

Primary amenorrhoea is where periods did not start at the time of puberty (between ages nine and 18). This could be related to long term chronic illness, extreme obesity, malnutrition or hormonal/gender identification conditions.

Hormonal checks will be carried out to identify the cause and treatment depends on the results. Some conditions can be treated with medication, lifestyle change or surgery. However, not all cases of amenorrhoea can be resolved as abnormalities of the genital structure or reproductive system cannot always be corrected.

Secondary amenorrhoea is when menstruation has occurred but has ceased for more than six months, not related to pregnancy. About 4% of women suffer from this and there can be many reasons. Anxiety, dramatic weight loss and obesity are the most common causes. It can also be found in athletic women. Once the cause has been identified, normal menstrual function usually returns after treatment.

Lea Taylor is a life and disability underwriter at Scottish Equitable Protect

Underwriting implications

Due to the nature of these conditions information can be limited causing delays in the underwriting process. Life cover can normally be offered at standard rate without approaching a GP. For critical illness cover, as long as malignancy has been ruled out and all investigations are complete and a full recovery made with no sequel, preferable terms can still be offered. For income protection, total and permanent disability and waiver of premium, underwriters are obviously more cautious and are more concerned about the long-term conditions which can cause time off work. Where appropriate, medical evidence is sought from the GP to establish the severity of the condition, any suffering of regular symptoms and if the individual has had any time off work. It will then be decided whether excluding certain conditions from the disability benefits should this be necessary.

For prompt underwriting decisions, it is vital that all the relevant details should be provided at application stage. Should the client be embarrassed disclosing details to any of these conditions, additional information can be submitted in a sealed envelope and addressed to the chief medical officer. This could prevent the underwriter from requesting further information causing unnecessary delay in offering acceptance terms.

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