Some of the least talked about female disorders are often the most commonly seen on application forms. Katie Bamber explains some of these conditions
A wide range of conditions disclosed on application forms can be classed as 'female conditions.' Those which underwriters most commonly see, excluding cancers, are explained below.
Endometriosis
Endometriosis is the presence of endometrial tissue ' endometrium ' normally present only as the lining of the uterus, outside of the uterus.
The endometrial tissue may occur in the fallopian tubes, on the ovaries, deep within the muscular wall of the womb itself, scattered about the interior of the pelvis, or even further away from the uterus in such remote sites as anywhere in the abdominal cavity. Wherever it may be situated, endometrial tissue is affected by the hormones that control the menstrual cycle. It therefore goes through the same sequence of changes that affect the uterine lining, including the monthly casting-off of blood, mucus and surface tissue. Because the blood and other material produced at these abnormal sites cannot usually escape, they accumulate and pain occurs with each menstrual period. Symptoms depend on the size and site of the endometrium. Common symptoms are pelvic pain and rectal discomfort, dyspareunia (painful intercourse), an abnormal menstrual cycle, dysmenorrhoea (painful menstruation) and occasionally, sterility.
Ovarian cyst/polycystic ovaries
The definition of an ovarian cyst is a functional cyst of the ovary which is common and benign. Benign follicular cysts are relatively common during the reproductive years. If there are multiple cysts then the diagnosis of polycystic ovarian syndrome is likely. Cysts may be present with menstrual dysfunction, infertility or be asymptomatic. They often pass undetected, especially in younger women and are of no consequence. But persistent cysts raise the possibility of malignancy especially for women over 50 as half of ovarian masses are malignant. Cysts may occasionally rupture and cause acute abdominal emergency or give rise to a mass, requiring investigation.
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is a chronic infection affecting the uterus, the fallopian tubes and the nearby structures in the lower abdomen. In over 80% of cases, PID is caused by organisms transmitted by sexual intercourse, namely chlamydia, mycoplasma and gonococcal infection (gonorrhea). It can also follow an infection acquired after childbirth or be caused by the use of intrauterine devices (IUDs). Rarely, is it a complication of inflammatory bowel disease. Symptoms include fever, vaginal discharge and severe pain, but these may be absent. A small percentage of sufferers will develop scarred fallopian tubes, which can cause difficulties with conceiving in the future.
Fibroids
Fibroids are common benign growths of uterine muscle. They exist sometimes singularly, but most often are multiple and range in size from microscopic to filling the whole of the lower abdomen. They are more common in obese women and those who have no children and may be detected in up to a quarter of women. Uterine fibroids are usually asymptomatic. However, fibromata in the uterus may lead to pelvic discomfort, menorrhagia (excessive uterine bleeding) or dysmenorrhoea or, if large, may cause complications during pregnancy or cause urinary obstruction.
Menstrual disorders
These consist of dysmenorrhoea; menorrhagia and metrorrhagia; and amenorrhoea and oligomenorrhoea.
• Dysmenorrhoea ' painful menstruation, symptoms occur just before, or at the beginning of the period, and consist of cramping, rhythmical pain in the lower abdomen and back, usually lasting for a few hours, but sometimes for an entire day. In severe cases they may last throughout the whole menstrual period. The pain is caused by strong contractions of the womb and with opening (dilatation) of the neck of the womb (the cervix). In effect, dysmenorrhoea mimics a mini labour. There may also be nausea, vomiting and diarrhoea, and cramping, colicky pains in the bowels. Some women feel faint and around 10% of women are so severely affected that they are temporarily unable to work.
• Menorrhagia/metrorrhagia ' menorrhagia is excessive uterine bleeding during a menstrual period. Metrorrhagia describes bleeding between periods. Heaviness of periods is relative. For some women bleeding for seven or eight days with frequent passing of clots is normal. But for a woman whose normal period is three to four days of light bleeding, a period like that would represent menorrhagia. Menstrual control is a delicately controlled hormonal balance which can be easily disturbed in some women. Aside from hormonal imbalance, other causes of uterine bleeding include disease of the ovaries, pelvic inflammatory disease, uterine tumours including fibroids and various systemic diseases, including coagulation (Von Willebrand's disease) and platelet disorders (thrombocytopenia). When no obvious cause can be found, the bleeding is termed dysfunctional ' or functional ' uterine bleeding.
• Amenorrhoea/oligomenorrhoea ' the absence of menstruation (amenorrhoea), or markedly irregular, infrequent menstruation (oligomenorrhoea). Primary amenorrhoea occurs when menstruation does not occur at puberty ' sometimes associated with delayed puberty. Secondary amenorrhoea occurs after puberty, for example, cessation of a previously normal menstrual flow. This is normal before puberty and after the menopause. During the reproductive years, the commonest cause of secondary amenorrhoea is pregnancy and lacetation, but it can be caused by a number of hormonal and other disorders. Gross disturbances of diet as in anorexia nervosa, excessive exercise as in female athletes, excessive stress, and disorders of the ovaries particularly polycystic ovarian syndrome ' uterus, pituitary, thyroid and adrenal glands may all lead to amenorrhoea. Amenorrhoea may occur with advanced renal failure.
Menopause/HRT
The menopause is the natural end of the sequence of menstrual periods and the end of the fertile years of life in a woman. The menopause occurs at an average age of about 50, with a usual range from age 47 to 52. Occurrences outside this range are quite common. A premature menopause occurs if the ovaries are removed surgically (ophorectomy), or there are other irreversible causes of hypogonadism. The menopause involves cessation of ovulation by the ovaries and the resultant hormonal changes which cause menstruation. Ovulation may become irregular, with non-ovulating cycles occurring frequently as the menopause approaches. The main effect of the menopause is a reduced production of the hormone oestrogen by the ovaries and most of the physical effects associated with the menopause are due to oestrogen deficiency. The common menopausal symptoms are hot flushes, night sweats, insomnia, headaches and general irritability. The menopausal syndrome refers to a period of physical symptoms and psychological changes which include increased frequency of urinary tract infections, irritation of the vulva, dyspareunia and depression occurs in some women. Hormone replacement therapy (HRT) is a treatment with oestrogen preparation to alleviate menopausal symptoms and tries to retard or prevent the progression of osteoporosis.
Abnormal cervical smears
Women are encouraged to undergo routine cervical smears tests. This screening can detect pre-cancerous changes and any appropriate action can be taken at an early stage. The screenings can reveal varying degrees of dysplasia or cervical intraepithelial neoplasia (CIN). CIN 1 indicates mild dysplasia (abnormal cell development), CIN 2 indicates moderate dysplasia and CIN 3 indicates severe dysplasia or carcinoma in situ. Most are easily treated and patients are usually asked to have regular follow-up smears, usually at six-monthly intervals.
Pregnancy or ectopic pregnancy
Pregnancy-related mortality in normal healthy women in the UK is minimal. Those deaths that do occur are usually due to haemorrhage or embolism. Those most at risk are older women or women who have had no prenatal care. An ectopic pregnancy is where development of the foetus takes place outside of the uterus ' usually in one of the fallopian tubes. As the foetus grows it may cause the fallopian tube to rupture. If this happens, any resulting haemorrhage can lead to death. Those most at risk are women who have a history of either pelvic inflammatory disease, infertility, endometriosis or have had a previous ectopic pregnancy. Ectopic pregnancies usually cause symptoms which lead women to seek help between the fourth and tenth week pregnancy and most commonly between six and seven weeks.
Pre-eclampsia or eclampsia
Pre-eclampsia is the onset of hypertension with proteinuria (which may be associated with oedema) between the twentieth week of pregnancy and the first week post-partum. Pre-eclampsia may progress to eclampsia where the blood pressure rises further and is associated with the onset of coma and/or convulsions. Major metabolic changes may occur in these disorders including a coagulo-pathy ' low platelets and disseminated intravascular coagulation ' hyperuricaemia and liver damage.
Mild pre-eclampsia is defined as blood pressure of 140/90, albuminuria of at least 30 mg/dl (+) and oedema. Severe pre-eclampsia is defined as blood pressure of 150/110 with marked albuminuria (up to 15g per day) or oedema. Pre-eclampsia occurs in approximately 5% of pregnant women, primarily primagravidas or those with existing renal, vascular or hypertensive disease. It is more common in multiple pregnancy. Around one in 200 pre-eclamptics progress to eclampsia. Placental factors appear to be important in causing the hypertension and proteinuria of pre-eclampsia by alterations in endothelial function within the expectant mother.
Katie Bamber is a life and disability underwriter at Scottish Equitable Protect
Underwriting implications
In the majority of cases, most benefits will eventually be accepted at standard terms as long as all complaints are confirmed as benign and a full recovery has been made.
However, delays can occur in the underwriting process. This will usually be due to the applicant having provided only limited information causing the underwriter to make further enquiries. Where full information is made readily available to the underwriter, terms can often be offered almost immediately.
Applicants should be encouraged to supply as much information as possible with the original application. If necessary, the client should be allowed to put details on a separate piece of paper which can be placed in a sealed envelope and submitted with the application. If the underwriter still requires further clarification on certain points, they may ask the applicant for further details. Alternatively, a medical attendant's report may be requested to obtain the necessary information.
