Gyn A Note
Gyn A Note
Gyn A Note
E .a
',
WhiteKnightLove
61 C0andooh
hy
DK- CDohffine,d A CDan doot,
of Obst&ics
Hssistant pxofessoK _Gy necology
Hin 6hams Univexsity
WhiteKnightLove
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Chapter 2: Endocrinology
Puberty 28
Menopause 31
Amenorrhea 36
Anovulation-PCO 46
Abormal bleeding 56
Dysmenorrhea 64
Ghapter 3: lnfertility
Etiology 68
Assessment 71
Treatment 76
Assisted reporoduction 80
Chapter 4: Gontraception
Physiological 84
Mechanical 85
IUCD 86
Hormonal contraception 90
Surgical sterilization 97
Ghapter 5: lnfection
Vaginal discharge 100
Sexually transmitted disease 102
Vulvovaginitis 107
Cervicitis 110
Pelvic inflammatory disease 114
Chronic granulomatous disease 119
WhiteKnightLove
My 2 Aims in this book to be SIMPLE and COMPLETE, so I
Dr Mohamed Elmandooh
WhiteKnightLove
A.^,..tovwV
€,trbryology
PLy=Lologv
WhiteKnightLove
?/rernln/? r4
Cornu
Anatomical internal os
lateml fornix
Excernal os
VaSina
Uterus
B lodder
..fornix
Anterior
Vogincfz fornix
Nulliporous os Porolrs os
Supo-
voginol
rtion
The cervicol conol is
fusiform qnd morked by cu-
rious folds colled ihe iorbor
vitoet.
The cervix is divided
into supro- ond infrovoginol
porfions by the ottochmenfs
of ihe vogino. The infro-
voginol port is olso colled
the rportio voginolisr.
WhiteKnightLove
O^,o.tov*.yv A3lpllea3 s.Batr*v ffi
) Structure
- Hollow pear shaped muscular organ
- Dimensions :3x2x1' but (3Vz x2Vzx l7z in multi-gravida)
- Weight :50 gm but (70-80 gm in multi-gravida)
) Psrie
2- Cervix
o Lower 1A I inch
o Peritoneum -+ cover it only posteriorly
o Muscle layer - mainly formed of fibrous tissue (ms: 10% only)
o Cervical canal -+ fusiform with^
* internol :34 mm
o
2 os
externol : rounded, becomes slit shape in MP
o
* 2 Pafts
- Part projecting in vag. 4 portio vaginalis (lined by st.sq.epith.= ectocervix)
- Part above v4gina O suprovaginal part (lined by colum, epith =endoceruix):
lb mucosa is thrown into folds into rartrich racemose glands open
* 2 junctions
- Sqnamocolumnarjunction (TZ) between ectocertix & endocervix
- Histological internal os + between endoceruix & endometrium
WhiteKnightLove
Physiologicol
Blodder
Cervix
Pc lv ic
' Brim
Blodder
--.Cewix beginning to oPen
. Ndool onus
SogiEo, sedron offie pdvb, wrdr dre womon h the ercct Position
WhiteKnightLove
I
Basic Science
3. lsthmus
n 3-5 mm
n Between atomical internal os above and Histological internal os below
n Covered by loose peritoneum
o In pregnancy forms -+ the bwer uterine segrrent (10cm)
o It differs from the upper segment in o
WhiteKnightLove
Rrboc€ryical llgament
gh',
pouch
Thefuomc,tB'of tE @tx
Round
Tronsverse i-Tronwerc
cervicql
ligoment
Pectum
WhiteKnightLove
) SuDDorts of ths uterus A
- AVF position
- Peritoneal attachment
- Position of the surrounding viscera
- {/ lJrm,ne UcA}tENTs (Tnus Orrrw) " rl. * I*gt,AToR ANt O
AI
'r Fold of peritoneum between latsaluterine border & lateral pelvic wall
Contents (all are present in loose CT; the parametrium) @
- Upper border: (medially -+ F.tube, laterally + infi:ndibulopelvic lig.)
- Uterine & ovarian vessels
- Vestigial remnants (epoophron, paroophron, Garfirer duct)
BI
I From uterine cornu througfu inguinal canal to insert n labiq majora
. Raises a ridge on the anterior (inferior) layer of broad ligmrent o
r Important to maintain anteversio
I Supplied by Sampson a. (ftom ovarian a.) & br. from infedor epigastric a.
CI + uteromcral llg.
r From back of cervix to middle sacral piece
r Formed of 2 pairs (swrounds the rectum)
r THE oI{l-Y TRUE li&; "
(others are condensed CT, smooth ms, elastic fibers)
WhiteKnightLove
lnterstitiol port lsthmus Amsdjs nfundibulum 2cm
lcm long ond 2cm long, stroight 5cm long, thin long. The terminol
very nqrrow ond cord-like. wolled ord exponsion, with
(less thon lmm). lmm diqmeter. convoluted. briol process€s
\ I
\
which help
I to ottroct
the ovum
{1t
l,:t
*. ovorium
,",rr\ ll ,
WhiteKnightLove
I
Basic Science
- Fallopian tub€s -
. Length -+10 cm ( inch)
. Extend from the cornu to open at the infundibulum
. Present in the free border of the broad ligament
) Perts lntsrdltlal
> Blood suDDlg 4 uterine & ovarian vs (double supply .'. tubal gangrene is rare)
- Ovarg -
> Posft,oh
. Lies in the fossa ovarica (a depression in the lateral pelvic wall)
r The ureter & int. iliac artery are passing longitudinally behind it
a @onneded to back of broad ligament by mesovarium"
t @onneded to uterus by ovarian ligament
) Qonneded to pelvic side wall by infundibulopelvic lisament
> Size almond shaped + 3x 2x I cm (5 gm)
> Strucfure
. Hilum + vessels, lyr.phatics, nerves enter & leave through it
. Medulla -+ vascular CT stroma. ....small in size
. Cortex -+ follicles, colpus luteum & albicans. .. . . .main compartment
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Urethri i* Rstrum
- Posferior fornix
nterior fornix
--Ureter
rigone
blodder
Loterol ,-(\
fornix
I /-- Vogino
WhiteKnightLove
> StructuDs
. Elastic fibromuscular canal extending from vulva to uterus
. The orifice is partially closed by hymen in virgins
. Cervix projects into the upper part of anterior wall -+ 4 fornices o
Anterior shallow..........Posterior deep.........2 lateral fornices
( .'. the anterior wall is 8 cm while posterior wall is lO cm o
> Relstlohg
o Ant. # lower 7a: (urethra).........upper45:. (bladder)
o Post.a (lower 7s: perineal body)...(mid 7s: rectum)...(upper 7s: D.pouch)
o lrat. 62 ureter.....levator ani & ischiorectal fossa....Bartholin gland
> Wsll
a turo umlls (anterior + posterior) opposed to each other (potential space)
- transverse section. .....O.....H-shaped
- longitudinal section....o.....Flask shaped
t l)'luxle --+ 2layers (outer longitudinal, inner circular)
. Epkhellum (mucosa, vag. skin)
lI Stratified squamous epithelium non-keratinized
2I Thrown into folds (rugae + allow distensibility)
3I No glands / o
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Thewlvo of ov*gin
-,--* -- PrepG -l
-L----Glm fofCllrcrts
\- '' FrorIm I
+-- Vhrtlbulc
Hylm
Fordrue
ons pubis
j- -- Prepuce
-- C litoris
- Fourchefte
Bortholinrs glonds
WhiteKnightLove
1-Mons Publs (mons veneds)
o Pad of fat covering symphysis pubis -+ act as cushion during intercourse
o Covered by inverted V hair, while in male -+ apex may reach umbilicus
3- (nymphae)
Lqblq mlnorq
o Two skin folds enclosed within the labia majora, each one will
-
sPlit.antedrorlvto enclosifff'Yiil
prepuceanteriorly
. The lower flap will form -+ the Frenulurn posteriorly
- Join together posteriorly to form -+ lhe@.
o
The depression between the fourchette & hymen is
present only in virgins & calledfu$s navicular!!
o Formed of
- Thin redundant skin (no-keratin + no hair follicles + no fat) o
- Pink colored -+ vascular connective tissue
4- Clttorls
o Length o21cm longo...... ...2-3 cm above urethra "
o Def . 4 v. sensith,e (t nerye supply) erectife (2 corpora cavemosa) tissue
o Parts 4 Etans (between prepuce & frenulum)......6odry.....2 crura
5- Vestlbule
o The area o within the two labia minora) It receives the openings
of:- - External urethral meatus
- Vaginal introitus (orifice)
- 2 Bartholin ducts
WhiteKnightLove
Sup€.trdal dbre.don
Deep€r dbractton
lschlmlcmosus rude
Sphlncter ui€dtru
qtcf,tc
&rlbomnosumwle
t/e*ibullr bulb
lshhl albcGlry
Bartholin's ghnd
Bulb of
zvestibule
-- Bortholin ,s
g lond
WhiteKnightLove
6- Vestlbulsr bqlbs
o Two small collections of vascular sponry C.T.
o They lie on either sides of vaginal opening -+ act as a cushion
o They are continuous above with the clitoris
. They lie deep to balbo-sponsiosus muscle
7- Exlemcl urethrsl tnestus
o The female w€thra is 4 cm long o
o Urethra is lined by transitional epith.....the ext. meatus -+ st.sq.epith o
8- llsmen
. Thin membrane partially separating vasnal orffice from restbule
- FormedII of e CT lined on both sides by statified sq. epithelium
-
Types'o cresentic, septate, cribriform, annular /,lmperlorate X
o Afler deflorotion (lscoitus) + slight spotting (relatively vascular i)
o After lobor -+ remnants are called: caraunculae myrtiformis
9-
o ilo: . One on either side of the v4gina
o
. Embedded in the posterior 7s of the vestibular bulb
o *ry&nc
- Sizo of a pea (nonnally oan't be felt except if infected: abscess)
- Compound racemose glands, Its duct is 2-3 cm long + qpens
on either side ofthe vagrnal introitrs (5, 7 o'clock)
c Puncllon: alkaline vaginal secretion for lubrication during intercourse
stood'ouppt+" o
: I#:i,'": ,:.ilH#ffi'#'"?rnar pudendar)
lnfundlbulo
pdrlclEilGtt
C.nl-d+rc
(dDot$s) t t rosacnl lE rolt
ThG lmoh p*vlc orgorF ir,,^dfio,n hd,t,'d, Onthebftthe od<hrEord tory orcbtthe pGitin ltundh dlo;oo dte 7,8rtr
dsedion hos becn mode'
?noslonoeis
urith I
ovoO'Alt
d.,p
doirl
.crd}6l
4liu;
- Pudendal
Risht
ovorlon
vein -----
Ovorion <(
orteries
lnlerior -'
mesenieric
orlery
in[. t.ta{1.
Labi.L porio..l
WhiteKnightLove
Basic Science I
- Blood supplu of Pelvis -
> Internal iliac artery " OO
Antodbi dtoehn
l- Visceral
* Uterine l-Ilio-lumbar
* Superior vesical (obliterated umbilical)
* Inferior vesical (vaginal) 2-!atenlqacral
* Middle rectal (hemorroidal)
2- Muscular branch (obturator) 3 erior gluteal
3- Terminal branches (inf
Uterine artery
o The main vessel, a branch from the anterior division of IIA
o They are tortuous (to allow uterine expansion during pregnancy)
o It runs mediallv to cross above o the lower end of the ureter
lateral to the supravaginal part of the cervix
o Then it tums upwards at the lateral border of the uterus
within the leaflet of the broad ligament.
o Branches:
. To the ureter
. Circular branch -+ to the cervix
. Descending branch --+ to the vagina (cervico-vaginal)
. fucending branch -+ gives arcuate (coronary) arteries
.'. the midline of the uterus is the least vascular
Radial arteries arise from the anterior & posterior
arcuate arteries to perforate the endometrium. They
will finally divide to
l- Basal artery....supplies basal parts only
ies the more
. Finally, it anastomoses with branches of ovarian a. at the cornuo
Ovarian artery
o Arises from aorta at L2 (iust below the renal artery) '
o At the pelvic brim, it crosses the external iliac vessels & enters
the pelvis in the iryfundibulo-pelvic ligament to reach the
mesovarium and enter the ovary through the hilum
o
o Left ovarian vein --+ drains into the left renal vein
o
o Right ovarian vein --+ drains into the inferior vena cava
WhiteKnightLove
Foscio
wiih
nerves
Vossels
- Peritoneum
,'^.. 'Urogenitol
'.. trionclc'
lschiol
tuberrosjtt
f
Socro- \
Uterosocrql tvberans
ligoment ligoment -,1 .
Levotor oni
l/::: '
Oblurolor
internus
Ischiorecta I
fosso --
Urogenito I
of
The ischiorectol fof is diophrogm -
trqversed by the pudendol
vessels ond nerves ond some shows ihe relolion-
smoll perineol bronches of nd pelvic floor.
socrol nerves.
This pod of fot supports
fhe onol conol ond pelvic
diophrogm.
Perineol body lsch iocovernosus
Tronsversus
\ \r
- -Bu I bospong iosus
perinei
su perfic iqlis Urogen ito I
Y. diophrogm
Levotor oni
-- Coccygeus
WhiteKnightLove
[ll Pstu,c De]itoheurn
- It extends from over the bladder to the Uterovesical pouch then
over the ulerus then to the posterior surface o of cx &
o
vagina (Douelas pouch) then to the anterior surface of
the rectum (lower 7e of rectum not covered)o
- Lxerally + the two peritoneal folds form the broad ligament
[4] Perineurn.., 2 .5 cm
> The area extending between skin (below) & the pelvic diaphragm (above)
> Divided into 2 pouches (superficial & deep) separated by a perineal memb
o Perineal body
- Fibromuscular pyramidal condensation
- Lies between vagina & anal canal
- Formed by decussation of 8 muscles
o Ischiorectal fossa
- Wedge shaped space on either side of anal canal filled by fat
- Boundaries
. Superior & medially -+ levator ani
. Lat.-+ obturator ms & fascia (splits to form pudendal: Alcock's canal)
. lnferiorly + skin
WhiteKnightLove
Left uBrine
Cut ed$ o, artory
parltorcum
Venous plexus
ReGum
CuFde.ec
: --- Pubo-urclhro,lis
- -- Prbo-vqeinolls
+ P,.bo- reetalis
WhiteKnightLove
. Origin: From back of S. pubis & anterior part of white line
(a thickening in the obturator fascia)
. Insertion:
- Side walls of urethra + Pubourethralis
- Side walls of vagina+ Pubovaginalis (fibers of Lushka)
- Side walls of rectum + Puborectalis
- Tip of cocclx & anococcygeal raphe -+ pubococcygeus proper
$ lfiococsvaeus
r From white line to perineal body, anococcygeal raphe & coccyx
> lscfiiococclrscus
4*
-l+t
From ischial spine to coccyx & sacrum
Nerve supply
* Pudendal n. Szsr -+ perineal surface (covered by inf. pelvic fascia)
* Branches of Ssl roots -+ pelvic surface (covered by sup. pelvic fascia)
Function
- Support ofviscera
- Maintain intrabdominal pressure
- Sphincter to urethra, vagina & rectum
- Important role in labor (rotation)
WhiteKnightLove
Pooton oilmry
AffidlubEfth
tbm]try
(twhudu.c)
Trigone of
Ureter------
infernol ilioc ortery
,From
Commonilioc Frorn uterine ortory
Uterus --_ ry
// ,,
z/ voginol ortery
-..Frdn
"*-'- - -'From vesi col ortery
WhiteKnightLove
Basic Science 11
r
- Pelvic Uneter -
Cource (10-lScm)
'k The ureter enters the pelvis by crossine the bifurcation of the
common iliac artery.
* It then passes downwards infront the internal iliac vessels to become
medial to them & behindthe infundibulopelvic ligament & ovary
* Just above the level of the ischial spine, it curves medially &
forwards to pass through the ureteric canal (in the Mackenrodt
ligament) till it reaches the bladder trigone
t It is crossed by the uterine arterJt o at the base of the broad
ligament. Here the ureter is 2 cm lateral lD et & 2 cm above
vaqinal vault
. Pre-oDerative ,+ IVP
. Intra-operative
- Proper identification of its anatomical course
- Clamping must onlybe done under vision
- Clamping must be near to the uterus
+
lnlury mov be
- Direct + cutting, crushing, suturing
- Indirect --+ devasculaiz.ation in radical hysterectomy / post-radiation
'Leods lo
- Hydroureter --+ hydronephrosis + renal atrophy
- Fistula formation
WhiteKnightLove
Pudendol
'.-'--orlery
/
tiI lsch
t.
, sPrne
..'',u \
| 7n:
-."*t...
Piriformis 52 z ,/ 'l//h
^1
muscle
\i
WhiteKnightLove
lVlognlUde of the problem
o It means all procedures that involve partial I total removal of
external genitalia for cufturaf non-tfierapeutir reas ons
o It is still practiced in Egypt, Sudan (tradition? African? religious?)
o It is totally condemned by WHO; practiced only if
* Cosmetic (chafing: roughness)
* Simple hypertrophy of labia minora (dyspareunia)
* Nymphomania
IUHO closslflcotlon
.
TVPe I,+ excision of part (prepuce) or the whole clitoris
.
TVpe ll
".) as above + labia minora
.
TVPg lll "+ excision of all external genrtalia+ narrowing of introitus
(Sudanese circumcision, infibulation)
.
Typo lU ,,+ unclassified e.g. piercing, tattooing
Compllcotlons later on
oo . Severe pain . Psychological, sexual troubles
. Hemorrhage, infection . Recurrent UTI
. Injury to urethra . Retention dermoid cyst
. Obstructed labor d.t. fibrosis
2- Porosvmoolhetic Sz,s. +
Preganglionic fibers (9 Pelvic / Splanchnic) pass along
with the pudendal nerves + relay at ganglia in or near
wall of viscera
*NB
. Thepelvic placus (loferlor hwo€astrtc plexus) : O + I
. The cervix is only sensitive to dilatation
. The body is only sensitive to distension
. Vulv4 perineum,lower 1/+ vagina'+ all somatic
WhiteKnightLove
Spinol cord
of
WhiteKnightLove
€,-,bryology
* lntrc-uterlns
. The primitive gem cells appear in the wall of yolk sac (near the
hindgut) at the 3'd week. These cells migrate along dorsal
mesentery to reach the genital ridge (which is the medial thickened
part ofthe urogenital ridge)
. Germ cells t
will markedly in number by mitosis to reach a
ma)dmum of 6-7 million at the 20u week. Then mitosis stops
and the oogonia will start the 1$ reduction division (meiosis) in
which they will be arrested in prophase
r An out-growth from the surface epithelium into the substance of the
ovary will form the sex cords, while some cells from the
mesenchyme will form the sex stoma
- The setc cords erwelop the oocyte toform the sranulosa cells
- The sex stroma will form the theca cells (as an outer layer)
6 Rt blrth
A large number of lv follicles will be lost in intrauterine life by a
process of apoptosis (programmed cell death). Thus, follicles are
* iftor puberty
A certain number of primordial follicles (400-1000) in each cycle will
resume meiosis. Only 1 will become fully mature (the dominant
follicle) ,+ lry oocyte + l't polar body, while the remainder will
undergo atresia. izatlron, the 2"d meiotic division (mitotic
occtr
like) will e + a2n polar body
* Formotlon of llgoments
o
WhiteKnightLove
- -iesonephric
Poro-
groovc
I
I
I
bocomes
i
I
Porq-
mesonephric
' ducl
gonad
--
-Mesonephric
ducl
Mesonephros
tI ro,
Testis
bonod S$toli
6lls
ducl
---Mesonephric Molb.ian
-- -Ureter lnhibltor
8e
--cloo"o
M0floIiil
cgr$ion
i/tal€ dffdmlhuon.
Foll6pion or Developing
-- uterus
// Mu llerion
r.)
Dege .--
*i: -
oting
tubercle
mesonephric
duct (becomes '--.- \ rogenitol
Gortnerts duct) sinus
WhiteKnightLove
* In Males
. The WoWan duct (mesonephric) develops under effect of
SRY: Sex determining Region of Y chromosome)
( testosterone production from fudlg cells
. The Mullerian duct (para-mesonephric) regress under effect of
MIF o (Mull. inhibitory factor): AIVIH (anti-Mull. hormone)
( produced bySerof cells in testis
. o
Vestigial remnants rruy be found between the 2 layers of broad lig &
o
may leadto formation of large (paraovarian / br.ligamentary) cysts
l. KoBLET TUBULES '+ at outer part of broad ligament
2. Hvoern oF MoRGAGNI ,* rroar tubal fimbria
3. EpoopnnoN,+ between ovary & tube
4. PenooptnoN,'+ between ovary & uterus
5. Gennrcn DUCT "+ runs medially below the tube then -+ lateral to
uterus, cx, vagina -+ ends at the clitoris (forms Gartner cysts)
* ln Females
. lndifferent stage:
The Mullerian duct develops in the lateral part of the urogenital
ridge as a longitudinal invagination ofthe coelomic epithelium
. Control
- Absence of AMH + Mullerian ducts persists
- Absence oftestost. + Wolffian ducts ureteric bud)
This means........femininity rs the Nnumel state
& masculinity is the superimposed character "
Further developnrcnt
- Mullerian duct passes downwards & curves medially to fuse
with the opposite duct in the midline. Then, absorption of the
intervening septum will occw from below upwards
- The horizontal unfused parts form ,+ the fallopian tube
- The longitudinal fused parts form,+ the uterus, rrpp". * of the vagina
- "*,
The lower end of Mullerian duct will project as a tubercle into the
urogenital sinus to form a solid vaginal plate
- Canalizatron ofthis plate (20wks) will form,+ !W.)6. ofthe vagina
- Junction between the Mullerian duct & urogenital sinus,,+ the hymen
WhiteKnightLove
- Ureter
itoris
C loocol-
- C I
membrqne septum
:.'!- Lobium
j-, --- moius
Ureter
Hind guf
Genitol
tubercle
Z Urogenitol
slnus
Urogeniiol
-, G lons penis Urogenitolz
sinus. Primitive membrqne
\\ --
urethrcl Anql membrcne'
groove
scrotot>a
WhiteKnightLove
Basic Science 15
. Cloaca
- The urorectal septum divides the cloaca (5-6 weeks) into
.2 compartments: rectum & urogenital sinus
.2membrarres: anal & urogenital membranes
- The outmost part of the urogenital sinus forms -+ the vestibule
WhiteKnightLove
Ununited
of blodder
Floor of
urethro
The
vestibulor
onus
WhiteKnightLove
Basic Science 16
@ Ouaries
> Aplasia & hypoplasia
- C/O -+ amenorrhea, infertility
- Diagnosis -+ see amenorrhea
- Treatment -+ HRT by cyclic E & P. pregnancy is impossible
> Dysgenetic ovaries e.g. Turner syndrome
- C/O -+ lry amenorrhea, no 2ry sexual characters
- Diagnosis:
't Phenotype -+ characteristic
* Karyotype -+ 45xo or mosaic: 45xol46xx OR 45xo/46xy
* Ovaries -+ streak (fibrous) gonads
- Treatment: HRT. Pregnancy is impossible
> Accessory (supemumerary) ovary + no complaint (found in br. lig.)
> Abnormal descent -+ very rare (the ovary found in high position)
O Fallopian tubes
> Aplasia -+ infertility (+ aplasia of uterus)
> Hypoplasia -+ short, tortuous, narrow -+ infertility, ectopic
> Accessory ostia / diverticulum -) infertility, ectopic
@ Cervix
> Cervical atresia
- CiO -+ cryptomenorrhea & cyclic lower abdominal pain
- Diagnosis -+ inability to introduce sound
- Treatment -+ dilatation, lf failed -+ hysterectomy !
> Patulous interna! os O habitual abortion
> Congenital elongation of portiovaginalis
- C/O -+ dyspareunia
- D.D. --> prolapse
- Treatment -+ amputation if symptomatic
WhiteKnightLove
cervices.
WhiteKnightLove
O Uterus h
) Aplasia: lv amenorrhea, infertility
> Hypoplasia
* Types: known by uterine index a Conponrru length / (Cenvrcnl length x 2)
'
Rudimentary (very small solid organ)
:
Infantile (body : cervix I :2)
'
* clo
'
Pubescenf (body : cervix = 1 : 1)
- Amenorthea or hypomenorrhea
- Infertility or habitual abortion (in ascending manner)
* Diagnosis of uterine diseases o
o Esilg plsghshcg
- Habitual abortion IPTL (abnormal shape & vascularity)
- Ectopic pregnancy (in rudimentary horn)
. Lgte pregnqhcg 6, malpresentations as transverse lie & breech
. Lqbor
- Obstructed labor (malpresentations)
o
- Morbid adherence of the placenta (P.accreta)
* Treatment + according to complaint and type of defect
WhiteKnightLove
Complete obsence of vogino. There
is o slight depression over the hymen.
Normol coitus is not possible.
Hoemotocolpgg Only
the vogino is distended Hqemqtometro The Hoemotosolpinx ln
by oltered blood. uterus is qlso distended. longstonding coses the
tubes qre olso involved.
lmperforate hymen
WhiteKnightLove
I
Basic Science 18
@ Ua9ina Ca
o Treatment
I. Frank method -+ use of progressive dilators
2' Vaginoplastyrrio"'.
operation: dissection bet. bladder & rectum
. William's operation: creation of a labial pouch
3. Abdominal -+ colon vaginoplasty + skin graft or amnion graft
4. Laparoscopic -+ Vachetti operation (gradual traction of a ball)
WhiteKnightLove
Pre-gronuloso Gronuloso
cblls -cel ls
Early
e
utrsl (0.F0.9 mm)
Larg.
o"'
anH (1-5 m)
I FSH
Theco interno
'. /
cel ls Y Thecq
-Gronuloso \ 7'
t,,
7/externo
folliculi I
in ontrum
- Coronq
rodioto
- Zono pellucido
WhiteKnightLove
Basip $cience 19
> Anfiqlfotllcle
- Multiple fluid spaces between granulosa cells join together
to form a large antrum full of "E'. This high 'E' (t
inhibin) J pSF{ -+ J uromatization + t local
-
androgen -+ atresia of most follicles
- The antral follicle (tbe aoobaot folllcle) is immune against
o
this atresia as it has large number of FSH receptors
WhiteKnightLove
Ruptured
follicle -
Doy I 14 2-3
months
loier
-a--ls-- -\
l2
at '.a
-
WhiteKnightLove
(D Ovulotion: 13-15 "rhefertite phase"
( to t LH receptors
o LH stimulates androgen production theca cells to:
- Ensure complete atresia of the non-dominant follicles
- lncrease libido at midcycle
o Extrusion ofthe ovumm.b.d.t.
- Proteolytic enzymes (collagenase, hyaluronidase)
- Contraction of ovarian smooth muscle (by PG)
- Pressure efftct of the antrum folliculi
o The midcyclic t in I-g is short-lived d.t.
- Exhaustion ofthe LH stomge in the pituitary
- Loss of the +ve feedback stimulus of E
O Luteo! phose: 14 doysG
o CcL fornatloo
1] Proliferative stage O 'G'& 'T' cells multiply rapidly
2] Luteinization stage ca deposition of cholestelol -+ yellow
vacuolated cells + steroidogenesis -+ E & P
(peakr within a wed< i.e" day 21)
- Granulosa cells + lutein cells
- Theca cells + paralutein cells
3] Vascularization (mature CL) + the . . . . . .. vascular organ in the body
o cfate of C%
4] lr ruo pnecultrlcv a Rotrogression:
( E & P from CL + -ve feedback on LH & FSH
+ CL starts degeneration atthe22n day
-+ Corpus albicans + corpus fibrosum
- JB&P + menses * release of-ve inhibition on LH & FSH
t
-r tU & FSH + start of anew cycle
WhiteKnightLove
Eorly Lote
proliferotive proliferotive
phose phose
WhiteKnightLove
* 4 9bases v
* cFuclonal eodooetrluo
la5rers of
- Superficial (+b)......H. sensitive, contain spiral arteries -end arteries-
- Basal (1h)... .H. resistant, contain basal arteries -for regeneration-
* gryktologlcal layem of endooetrluo
- Stratum basalis... ..... ..(around gland bases). .....y4 thickness
- Stratum sponsiozum. . .(around gland bodies).. . .72 thickness
- Stratum compactum...(around gland necks)..... 7+ thickness
O Menstrua! phase (?
WhiteKnightLove
'Ferning' pottern in voginol smeor
due to oestrogen stimulotion.
WhiteKnightLove
Basic Science 22
I
X Alomal,menttuatfun 9 9
> Rhyihm a.regular every 21_35 days
(<21 polymenorrhea, >35 --oligomenorrhea)
) Durotion O average 3-5 days
(<2 :hypomenomhea, >7
=nenorrhagia)
) Amount a 50-80 cc: average 3 napkins /day
(<3 0 :hypomenorrhea, >80 :menorrhagia)
WhiteKnightLove
Hsrmonoa:
> Typos
- Estradiol (Ez) -+ most potent, most important o
- Estrone (Er) -+ less potent, estrogen of menopause
- Estriol (El) -+ least potent, very high levels in pregnancy
- Estetrol (Er) -+ very weak
> Sourco * Glands d ovory (GF,/./ + CL), ploconto, suprorenol cort@x
* rerlpheral conrrcrslon o of ondrogens (3O% of e)
> Itiotobollsn: 99Yo bound (SI{BG)... metabolized in liver
> flctlons O
-1- General - (anabolic & proliferation)
*
$tetabollc
- Protein -+ anabolic with nitrogen retention
- Lipid -+ protective effect against IHD (t HDL + J t-Ot-l
- CHO -+ some anti-insulin action
- Coagrrlation -+ t thrombosis (t clotting factors + J fibrinolysis)
iBom e) stimulates osteoblastic activity + growth spurt then closure
n
of the epiphysis. But it still protects against osteoporosis.
* t[odocrtoal sJ/steo
- Pituitarygfland: -ve feedback on FSH, +ve on LH -+ ovulation
- Breasts: Stimulates duct r system mainly + f vascularity + t fat
ln pregnancy -+ 1 prolactin release but blocks its action
- lmreasec all binding globulins (SHBG, TBG, cBG)
WhiteKnightLove
Basic Science 24
I
r Tvpes
l) il atual pugutewnn . ..utrogestan, duphoston
2) SyntfrPlic
o
I gonero
' "l2 ru o r r-+ Norethindrone, Noresthisterone, Norgestrel
o PREGNA&6-+ Medroxy progesterone acetate
| 2d ganarotion: Levonorgestrel
) 3'd ganerotion: (new progestins) : t pot"rr"y + .1, androgenic effects
Desogestrel (Marvelon) - Gestodene (Gynera) - Norgestimate (Cilest)
> Uses @
WhiteKnightLove
I
2s Qsw@4
WhiteKnightLove
> Source
- FSH, LH are secreted by the anterior pituitary (basophils)
o
> Chemlstry
o
They are all glycopeptides having similar u-chains, different B-chains
So in cases of assay ofHCG we do B-subunit assay
- Similar to LH o
> Uses @
o FSH & LH,+ induction of ovulation in:
. Hypothalami c failare, pit.uitary failure, clomiphene inducttonfailure
. Unexplained infertility
. Assisted reproductive techniques (ART)
. Male infertility
o HCG ,+
. Ovulation (tH like activity) given as 5.000 - 10.000 IU / IM
. Corpus luteum insufficiency
. Some cases of threatened abortion (instead of progesterone)
WhiteKnightLove
Jp-hydroxystetoid
I 7-Hydroxypregnenolone
progesterone
DEhydroepian<lrosterone
I 7-FJydroxyprogesterone
<__*
Testosteron€
I
I
I P4soa
I
V
Estradiol
WhiteKnightLove
> Functlon
o GnRH (previously LHRII) is a decapeptide wlttch stimulates
- Synthesis & storage of Gn (re*wa pool)
- Induce immediate release of gonadotropins (roleosoble pool)
o GnRH is released in pulsatile fashion (every horn)
> Conuol
o
O Negafnc feedbackloops
r Long feedback loop by ovarian steroids
. Short feedback loop by Gn
! Ulmshort feedback loop: GnRH inhibit its own release
O Neurofansmitter contol on the Hypothalamus
r Noradrenaline+tCnruf
. Dopamine, serotonin, p-endorphins - J GnRH
> [Jsas of GnRH onologues @
o Nasal Wray aNafarelin (synarel).... Buserelin (superfact)
o SC injectionO Goserelin (zoladex)
o IM injecti on o Triptorelin (decapeptyl). . . ..Leuprolide (lupron)
o
I lf used ln pulsatile mannor
( induction of ovulation (with no risk of OHSS )
2) fiused in continuous manner
* Down regulation of pituitary receptors -+ inhibition
of FSH & LH - J B (medical castration) .'. used for
- Superovulation+ART
- Contraception
- Some 'E' dependant tumors: fibroids, end.lryperplasia, EA
- Dysfunctional uterine bleeding
- Idiopathic precoc ious puberty ..... Idiopathic hirsutism
* So main side effect is + pseudo-menopausal state esp
Osteoporosrs .'.ADDBacrTrmne.pv of "E * P" may be given
o
Norraal
l{rcllnornal
lc.e7r. cK
WhiteKnightLove
F..b"rty
.Irvler^.ope\rse
q,^o.vrori3;:B
Qlo.rrrn ol bl""Jing
Dy=,,Ner^.o
,rlr.o
WhiteKnightLove
I ,(
E4dzrnlar?
IANNER STAOING
\l
/)
7re?ubertal
Y
Sexual hair
Ir l
Mid-esculcheon
Y
Femaleescuq,heon
FfiCWiat@nerr,]
us TAllllER qAsslFKATl0l{ s
Breast Publc hair
1 Pre-pub elevated breast oapillae Not oreseflt
2 1O yrs Breast bud -+ smal! mound Sparse on labia majora
3 11 yrs Furherenlaroement (round & small) Darker, coarser, curled
4 12 vrs 2'v mound (areola proiect out) Also on mons oubis
5 14 yrs Adultcontour (2ry mound disappear) Also on medialthioh
WhiteKnightLove
of tansition from chitdhood to odulthood physically ending
in full sexugl& reoroduclive development
. Puberty is aperiod oftime (8-13 yr), menarche is an event (l2yr)
WhiteKnightLove
Precodous puberty Delayed puberty
Thyrcld
o Hypothyroidism oHypothyroidism
Adnnd Adrcnel
oCongenital adrenal
hyperplasia
Ovay
oPCOS
oResirtant ovarv
syndrome
G.n dc
oTumer's svndrome
-McCune-Albright oPrader-Willl syndrome
syndlome o Laurenc+Moon-8ledl
svndrome
o /esticular femlnization
(X linked)
oGonadal dysgenesis (45XY)
oKallmann syndlome
WhiteKnightLove
Endocrinology 29
I
lodolasr;anca I h
lo Congenital a ambiguous genitalia (intersex)
o Traumatic ? circumcision. sexual abuse. accidental trauma (FB)
.. . .
o Delayed pueefly
Definition
) No menarche by 16
) No secondary sexual characters by 14
) No menarche for 5 years after completed thelarche
Etiology
- Constitutional /, malnutrition, chronic illness
- tgpergonadotrophic -+ ovarian failure
- lgpogonadotrophlc + hypothalamic - pituitary failure
- Normogonadotlophic -+ end-organ-insensitivity
(Mullerian agenesis, TFS, imperforate hymen)
lnvestigations
(
LH, FSH to differentiate the 3 types
- Hyper-gonadotrophic (FSH > 30 mru/ rnl-) - karyotyping
- Hypo-gonadotrophic (FSH < 10 mIU/ rnl,) -+ CT skull
- Normo-gonadotrophic -+ ultrasound pelvis
Treatment --> acc to cause
WhiteKnightLove
r
DIA6NO9TIC WORK-UP OF ?RECrcIOIJS ?UO:ERIY
t, on
'tuberculoais
. naurotibromatosis - hyVothyroidiom
'epilepay - aonqenital aAranal hyperplaaia
WhiteKnightLove
I
Endocrinology 30
@ ?rucocious pueeilg h
Appearance of any pubertal changes earlier than its mean by 2 SD
o
Approximately:- < 8 years for breast & < 10 years for menarche
Freotmend
o Of the CaUSe e.g. -+ surgery for ovarian tumor, thyroxin for Juv. hypothyroid.
o ISOSexUal,,+anti-estrogensttttillageof 12yr. ........4s inendometriosis
o Heterosexual,+ anti-androgen. .....as in hirsutism
WhiteKnightLove
Ilrc rcdualon h drestse ofdre derus rn oU qe
o cgrDnary heart
otSease
o myocadlal
inhrtlon
o stroke
WhiteKnightLove
_O,l_to ly otu4l_ cha ng
9_g
) J Ez ond inhibin -+ d.t. exhausted ovarian follicles
) t FSH / ond [H -+ d.t. loss of-ve feedback of EsP
) J P -+ but small amounts are secreted from the adrenal gland "
) T -+ continues to be secreted (adrenal -75%- & ovary -25%) by the
same levels as before menopause .'. there is a relative t in T "
Er + . produced by peripheral conversion from andr. (fat, liver, ms)
o
. the main posfinenopausal E -+ weaker than Ez
O Local Ghanges
) Ovqries + fibrotic, small, no follicles
) Ulerus -+ atrophy of all layers (atrophic endomet. is the /
cause of PMB)
) Cx, vulvo, vog + smooth, atrophic, J glycogen -+ alkaline -+ infection
) Supports of genilol lrocl -+ weakening -+ Prolapse or SUI
) Breosl-+ atrophy of glandular tissue * more fat deposition -+ small & flabby
@ Geruenel
) Hot flush (flosh)
- Sudden sense of heat & flushing in face, neck, chest d.t.
( attacks of VD + palpitation & sweating then VC + cold shiver
- Each attack last for few seconds + few minutes
( It may be repeated from twice lday -+ one /15 min
- Mostly due to hypothalamic instability associated with t FSH
) Cordiovosculor
- t I-OI- (dangerous) t J fpl-
Qrotective) -+ CHD
- Atherosclerosis (deposition of cholesterol) -+ hypertension
- Pdf Q *ve FH, diabetes, obesity
) Osleoporosis
- Progressive systemic bone resorption -+ O glrm -+ O fractures esp:-
( Cancellous bone: L.vertebra,femur neck, distal radius
- Peak bone mass is acquired at25 yrs -+ then rate of bone loss O
( From 0.5% lyr up to 2-3 o/o inpost-menop. life
- Pdf 4 *veFH, cigarette, alcohol, sedentary life, slimo ,white'
d chronic liver /renal, drugs (steroids, heparin, thyroxin)
WhiteKnightLove
I
qrlucrnh% r(
(+20%) +2SD
Mean
(-20%) -2SD
Fncure zom
50
Age (yeB)
WHO dlagnostlc c.t gorlcs for osteoporosis
Norm:l: Bone mineml density not more rhan ISD below
the man vialue for peak bone mass in young adults
WhiteKnightLove
Endocrinology 32
* AmlcERK a the peild during which the female passes from the
reproductive to post-menopausal stage (45-52 yrs)
* PtPttlsDPA0sE a period of life around menopause (before & 1 yr after)
* posrUnomosE a period of life after 1 yr from menopause
* pnrmlrunt Mo{oElosEo ovarian failure < 40 yrs
* tUotXO MhloPAUst a surgical / medical / irradiation
WhiteKnightLove
?lrrcrnlnT? ,1
No
proven Quality of life, dementia, cognitive function, sleep, depression, sexuality
efiect
WhiteKnightLove
I
Endocrinology 33
# clndications
l. S)tmptoms of estrogen deficiency (menopausal syndrome)
2. Asvmptomatic women with high risk for osteoporosis ot CHD
3. Routine for all postmenopausal women
4. Premature ovarian failure
# Conttaindications
Abcolute Relative
Unexplained vag.bleeding: cr ?? Endometriosis
Active liver disease - Chronic impaired liver function
- Gall bladder disease
- Recent myocardial infarction -Contolled hlpertension " & DM
o
# lMechaoism of acion
> Pmtsstion fiorn osteopomsls bg
- O action of osteoclasts (through inhibiting effect of parathormone)
- O Ca* (t Cff absorption, J renal loss, stimulation of calcitonin)
> Protec+lon from CVD bg
- O fDL, O I-OI- & cholesterol ) recently masked by
- O cholesterol deposition in vessels + VD ) the t in CV accidents
# lDuratloo of therapv
- Start at any age after menopause (never too late)
- Some say 10 years are the minimal
- Others -+ HRT must be given for life
- The most recent (& correct) + not recommended for > 2yrs ,/,/r/
WhiteKnightLove
34 q%enhrq r,
O EsrnoGENs Orulv (ERT)
> NoN-onar,
Drugs
ll Skin poich (estraderm) -+ applied twice weekly (0.05 mg)
2l Skin gel(estragel) -+ applied twice daily to arms or legs
3l Voginol Creom (premarin) -+ for atrophic vaginitis & dyspareunia
4l Subcutoneous lmplont 1mg -+ inserted in abdominalwall/ 6 m
WhiteKnightLove
O ruox-HoRMoNAL Dnucs
> SER^ /
- Selective Estogen Receptor Modulators (agonist antagonist) are
drugs which stimulate different estrogen receptors (a,P)..'.
. Exert estrogenic effects on desired tissues (CVS & bones)
. Avoids estrogen stimulation on others (uterus, breast)
- Commonest drugs are Tamortfen (1$ generation).... Raloxifen
0varian dlsordo13
. Anovulation, e.g. polycystic ovarian syndrom€ (pCoS)
. Gonadal dysgenBsls, e.g. Tumer's syndrome
. Promature ovarian failure
. Resistant ovary syndrome
Piluilary disordors
. Adonomas such as prolactinoma
. Pituitary necrosis, e.g. Sheehan's syndrom€
Hypolhalamlc mallunctlons
. Resulting from Bxcesslve exercise
. Resulting from woi0ht losyanorexia nervoM
. Resulting lrom stress
. Craoiopharyngioma
. Kallman's syndrome
HoemqtocolDos Onlv
the vogino is disfended Hqflnot"ometrq The Hoemotosolpinx ln
by oltered blood. uterus is olso distended. longsfonding coses the
tubes crre olso involved.
imperforate hymen
WhiteKnightLove
Endocrinology 36
* Amenorr$ea *
Types
S lrv omenorrheo
Absence of menstruation in a patient who has never menstruated
before, either at: 14 years -+ without 2ry sexual characters,
16 years -+ with 2v sexual characters
S 2'v omenorrheo
Cessation of menstruation for a period equal to
3 cycles -+ if previous menses were regular, or
6 months -+ if they were irregular or infrequent
Etiology
* +9fra,siotnoicol
- Before puberty,,+ Gonadotrophin secretion not yet established
- After menopouse "+ despite tt CrrnH (d.t. exhaustion of follicles)
- During pregnqncy/ / ,,+ continuous placental steroid production (E+P)
- During loclotion ,+ Prolactin Q- I GnRH, Z- J Gn action on ovary,
3- Jovarian steroidogenesis, 4- J action of E)
* 9affinlnaical.
(l Folse omenonhoo (Cryptomenorrhea)
> €tiologv (outfloru troct obstruction)
- Imperforate hymen / (the commonest cause )
o
WhiteKnightLove
37 qq.Krih?" r(
@ lrua amenorrhea OOO
o Sypotbalamus -rV- o
l - coneeoital syndromes
> Frohtich -+ n J GH RH -., J height, central obesity
* No GnRH -+ affionoffhea, genital hypoplasia, no 2'v sexualccc
s- Miscellaneous
> Hyporproloctlnomio of hgpotholomlc origln
( due to loss of -ve feedback of PIF (dopamine) by drugs / lesions
> Postplll omenorrheo (Sheormon syndrome)
( persistence of hypothalamic suppression after stopping COC
( If am. lasts > 6 months -+ search for causes other than pills
> Psychologlcol <onditions
i- Sovere stross (extreme grief - war), severe exercise or rapid weight
loss (Ballet dancers - Joggers) -+ t prolactin & B-endorphins
-+ J pulsatile GnRH secretion
WhiteKnightLove
I
EndocrinoJogrly 38
e 9ttuttary -III- a
r - coogenital
* LevFloraln syndrome:
= I
GH + J gonadotrophins -+ dwarfism * amenorrhea
2- Post-traumatic
3- Postinflammatorv ostriae'
-+ acne, hirsutism
4- pifuitary tumors | .,,","li"orosen
| - Pituitary (C.disease) -r basophil adenoma
- Adrenal (C.syndrome) -+ adenoma / adenocarcinoma
carcinoma of lung
* Sft2tfran'o diaeaae
> Etioloey
Panhypopituitarism due to necrosis of anterior pit after
WhiteKnightLove
NoY cfiromoeorne
NoTDF
No testost€rone
i No M0llerian
jlnhlbltor
Miilleilan
d€volopment
Failure of Uterus
development Ealloplan tubes
o, oocytes Cervlx
Vaglna
il Turnafs sydrom.
streaYovary
Turnerb syndrome. ODF, tostcuhr determinlng fac{or.)
WhiteKnightLove
I
Endocrinology 39
o 0vary -II- o
t - Coneenital
- Agenesis / Dysgenesis (pure, mixed, Tmer//, others)
- Testicular feminization syndrome
- Superfemale (47xxx)
2- Traumatic -+ oophrectomy (surgical, medical, irradiation)
3- lnflilnmatorv -+ mumps, T.B.
4- iileoplastic
- Destructive tumors -+ bilateral
- Secretory . O g ,+ estrogen producing tumors
. O ao,+ androgen secreting tumor
' Both "+ Polycystic ovarian disease /
s- Misce*aneous
- Premature ovarian failure - Hyperprolactinemia
- Resistant ovary syndrome - Hyperandrogenism
* irrnnersvnfiomd
o Clinical picture
- Genotype -+ 45 chromosomes (45xo) i.e. no Barr body'
OR \ Mosaic (45xo - 46xx) or Chimerism (45xo - 46xy)
\ may be tall / get menses -pregnant / but finally....POF
- Phenotype
. Short < 150 cm, webbed neck
. Shield chest (widely spaced nipples + underdeveloped breasts)
o
. Coarctation of aorta , cardiac & renal abnormalities
. Cubitus vulgus (wide carrying angle)
- Exlernol genitolio -+ infantile
- lnternol genitolio -+ streak ovaries (fibrous 6411ds * no follicles)
o Suspected in neonate by o -+ lymphedema of dorsum of hands & feet
+ Short 4n metacarpal
o Investigations: J B + t fSF{ (hypergonadotrophic hypogonadism)
o Treatment
l- Cyclic EsP
- To stimulate breasts, menstruation, prevents osteoporosis & CVD
- Not given < 13 yrs (bone age) to avoid premature closure of epiphysis
- Growth hormone can be added to increase height (+ 8cm)
2- Oophrectomy is done only in mosaic types with Y-chromosome
( risk of malignancy is -+ 25Yo: dysgerminoma
3- The only hope in pregnancy -+ oocyte donation r(
WhiteKnightLove
of
loaca
WhiteKnightLove
(Androgen Insensitivity Syndrome)
Pathogenesis
X-linked recessive diseases + absent or insensitive recqrtors in breasts,
hair follicle, vulva -+ no response to AltDRocENs secreted from testis
(i.e. end organ insensitivity) + .'. they develop in a feminine direction
Clinical picture
- Koryotype 4 46 XY (male)'
- Phenotype
* Complete form ,.+ attactive female with well developed breasts
(fat only - no glands) with small nipples,
pale areola" pubic & axillary hair are absent
* lncomplete form ,,+ variable degree of masculinized female
- lntemol genilolio d testis (found intra-abdominally, in a hemial sac,
in groin, in labia). They secrete a hormone from sertoli
cells (anti-Mullerian horurone) + no uterus, tubes
- Externol genitolio Q avaginalpouch o
Investigations
- Normal d level testosterone (> 300 ngldl)
- Normal d level estradiol (30 pg/mt) produced from
. Adrenals, testis, peripheral conversion (androstenedione to estrone)
. This small E amount is unopposed by T -+ breast development
- Nonnal FSH, LH levels
Treatment
1- Leave the patient till 16-18 years: to allow breast development
( followed by gonadectomy (a must as + malignancy is 25%o)
( followed by ERT (no need for progesterone):
To maintain the ferninine character, avoid osteoporosis, C\lD
2- For vaginal pouch -+ gradual dilatation orplastic surgery
* (Iriple X syndrome) M
- Genotype + 47xpr.OR48xxxx
- Phenotype + majority are normal (may have lowered IQ)
- External genitalia -+ infantile, amenorrhea, infertility
' Treatrnent + induction of ovulation
*au
- Partial deletion of short arm (46xx p-)
- Deletion of long arm (46m q-)
- Isochromosome of x chromosome
WhiteKnightLove
I
?/nzriln r/ /4
Ashermann svndrome
seen by hvsteroscope
WhiteKnightLove
Endocrinology 41
I
o cUterus -f- o
l - Conoenilql + aplasia, hypoplasia
2- lnflommolorv
3- Iroumolic -+ Hysterectomy or !
Asherman syndrome Ea
(amenorrhea traumatica, intrauterine synechiae)
o &iolngy:Q
- Ut. operations "+ excess DsC-basal layer-, myomectomy, metroplasty
manual removal of placenta, intra-cavitary radiation
- Ut. infections,+ septic abortion, puerperal sepsis, T.B. endometritis
o SWeo
t t€rirE adhesbns Tuba! octia
Evaluated by
lllnhal < /+ involved both are seen
Hysteroscopy
llodente Vt -3/+ involved one ls seen
Sanerc > 3/e involved none rs seen
o Srcalnwt
- Adhesiolyis,+ DaC (or better hysteroscopic) + 3n1i6io,i"t
- Avoid new adhesions by,+ Foley's catheter for 10 days
- Induce new endometrium,'+ cyclic E+P in high doses (CEE 2.5mgdaily)
o $eoeral o
Endocrine - Thyroid (hypo or hyper)
- Adrenal (hypo or hyper)
- Acromegaly
Generol debilitoting diseose - Severe anemia & malnutrition
- Chronic diseases as T.B. / D.M. / R.F.
Drugs - Drugs causing hyperprolactinemia fi
- Drugs containing hormones: . anabolic steroids, androgens I danazol
. continuous COC / progestins / CnRH
WhiteKnightLove
qrlrornlaq? r4
I Exclude pregnancy.
E Ask about perimenopausal symptoms (e.g ftushings,
vaginal dryness).
I Take a history including weight changes, drugs, medical
dlsdders and thyrcid symptoms.
I Cary out an exmination, looking particularly at height,
weight, visual fields and the presence o, hirsutism or
virilization Als cilry out a polvic examination, unless
thls is contraindicated
I Check smm lor LH, FSH, prolactin, testosterone,
thyrcxine and thyroid-stimulating hormone [tSH).
I Arange a transvaginal ultrasound scan, looking fd poly-
cystic ovaries
r Beview wlth the rsults .
WhiteKnightLove
s Assessmerfi s
O Historv r
Personal
- Age-*------to differentiate lry or 2v or physiological (<9 or >40)
- Maxital status-----to exclude pregnancy
- Parity-------------previous pregnancy
- Occupation-------stress / ballet dancers
Complainh -amenorrhea
l7-desmolase
1 7-ketoreductase
Hy p ot h a Ia m ic dy sfu nct i o n
Kallmannt syndrome
Tumors of hypothalamus (craniopharyngioma)
Constitutional delay of puberty
Severe hypothalamic dysfunction
Anorexia nervosa
Severe weight loss
Severe stress
Exercise
Pituitary disorder
Sheehan's syndrome
Panhypopituitarism
lsolated gonadotropin deficiency
Hemosiderosis (primarily from thalassemia major)
WhiteKnightLove
I
Endocrinology 43
@ Examination \
* Primary amenorrhea
r Geherql'+
.Phenotypic character. . ..Turner stigmata
.Pubertal development ....Tanner staging
t [acql ,+
.Hymen inspection. . ...cryptomenorrhea
.Clitromegaly. . . . . . . . . . . . ambiguous genitalia
.PR (in virgins)..........absent uterus
* Secondary amenorrhea
DM
^ Wslght . T}rtI.I -+ anorexia nervosa / hyperthyroid /
. OsssB -+ PCO / hypothyroid / Cushing i Frohlich / LMB
o
Uterus prceent (absent brcast) Boft present
. Acquired causes
( hypergonadotrophic hypogonadism (9ry omenorrheo)
.Pituitary & hypothalamic -9NDBoi,l6. - HPO- axis
( hypogonadotropic hypogonadism - Uterus
.General constifutional cause .Cryptomenorrhea
WhiteKnightLove
Karyotype:
Testicular feminization,
M0llerian agenesis,
46,XY steroid enzyme
pure gonadal dysgenesis, or
anorchia
lmperforate hyrnen,
transverse vaginal
or vaginal agenesis
Consider as if progesterone
challenge negative
(see figure 19-3)
Polycystic ovary
syndrome
Rule out ovarian tumor
Rule out adrenal tumor
Swere hypothalamic
dysfunction
WhiteKnightLove
Endocrinology u
€) lnvesfigafions \
O First of all -+ exclude presnancy -+ B-HCG "o
OThen determine level . Prolactin level.........
. TSH t T3, Ta.
OOthers:
> Huperandrogenism
- Adrenal gland investigations:
. DHEA-S -+ diagnose adrenal origin
. Cortisol & ACTH level -+ in Cushing
. l7-OH progesterone -+ in CAII
.CT/MRI -+ to exclude tumors
- Testosterone level (diagnose ovarian origin)
> Hyperprol actinemia. .. ..Prolactin level +CT brain
> lry amenorrhea
- Turner syndrome + karyotyping + laparoscopic ov. biopsy
- Mullerian agenesis -+ U/S (absent uterus)
- Test. Feminization -+ testosterone level
fgle of ctl$ lo aoeurbea
* Uterus...absent (Mullerian agenesis|IFS)...infantile (uterine index <1)
...absent normal trilaminar endomet is suggestive of Ascherman
t Clvarles........absent (Tumer).....swelling (PCO /functional cyst /neoplasm)
r Vagina & hematometra
WhiteKnightLove
q4r.anb% rl
Exclude physiological
causes:
o pregnancy
o lactation
o menopause
Asherman's syndrome
Sheehan's syndrome
Cervical stenosis
WhiteKnightLove
slftanogement s
OGeneral
r Correct anemia & malnutrition
r Reduction ofweight if obese
r Alleviate stress
o ltimaq amenonhea
r Norrno-gonq&tmDffc
\. Imperforatehymen ...cruciateincision
\.Mullerianagenesis,.. .neo-vagina(vaginoplasty)
\. Testicular feminization. . . ....gonadectomy at 18 yrs
r llgDo-ronq&tmDhlc
\. Hypoth-pituitary causes......cyclic HRT or HMG/HCG
r llgDoFgonqdot]oDhla
\. Ovarian (Turner)... ...cyclic HRT at 13 yrs
osecondary amenorhea
r Hormonsl
\. Cyclic HRT e POF
Cycloprogynova (estradiol valerate + norgestrel)
Yasmin /Gynera
Cyclic progestogen for 7-10 days /month
\. Induction of ovulation 4 PCO
Clomiphene citate (clomid)
HMG /HCG
\. HYPerProlactinemia
Dopamine agonists (parlodel - dopergine - dostinex)
\. HYPerandrogenism
Androcur (cyproterone acetate) / Spironolactone / Diane
\.Thyroid dysfunction
Eltroxin in hypothyroidism
Thiouracil in thyrotoxicosis
r Surdcql
\. PCO.. .........laparoscopic ovarian drilling
\. Asherman syndrome.. .......hysteroscopic resection
\. Pituitary adenoma only if....refractory to medical ttt
\. Resection of.... ........adrenal tumor
WhiteKnightLove
WhiteKnightLove
Endocrinology 46
I
* Xnovvfg,trofi *
E"H.d
Failure of ovulation, which may be classified into )
Group I Hypothalamic pituitary failure Low.. ....LH & FSH
Group ll Hvpothalamic pituitary dysfunction Normal...LH & FSH
Group lll Ovarian failure Hish......LH & FSH
@EelPlsqd
D C/P of anovulation
1. Menstrual inegularity -+ amenorrhea, oligo-hypomenorrhea, DUB
2.Infertility
) CIP of etiology (as in amenorrhea) *.....,.e.g:
1. PCO + SOFIA
2. Hyperprolactinemia -+ galactorrhea
3. Hyperandrogenism -+ hirsutism
4. Other endocrine disease -+ thyroid (goiter, tremors)
WhiteKnightLove
OF ?OLYCYSTI,
Diotubad ncwoendoarlna
.- Hypoilvlamua-Vttuitary
funotion ol aentr*l neruous t GnRH
oyatem )
l Estroqeno
(eef,rone and
eqtradiollTp)
I Tenpharal (extra-
,landular) ammarizailon
of androqana - eatroleno
AdipoecAede
t Estrudiol-1zg
I Andr n^dion
I Ovarlan androqa
1
I
V daNdroo?androate.one
J
Adranalgland A
I SHBG
I frcm llver
Polyclretic owrlcr
WhiteKnightLove
Endocrinology 4l
I
I. PolvcYsrrc OvnnnN SyNoRoME $
(Stein Leventhal Syndrome -1935)
[oanffi
. A syndrome ccc by d ov. dysfunction & loss ofnormal hormonal cyclicity
. Presented by o lnferlilily, ODeslty, Hlrsullsm,Onouulatlon
h'-qp!q!Ed
. Affects 5-10 oA of females in the reproductive age
. It is the commonest / ovaimcause of 2,v amenorrhea, chronic anov & infertility
. Etiology is unclear * p41ytL1qt. & csNe TENDENCv
WhiteKnightLove
48 fuernh% r,
DleeleEedE
O ..longtermrisks
o DaC -+ enffinefrfal hrrperplasia + circinofiut
o GTT -+ [M
o HDL, LDL, cholesterol -+ CUD
WhiteKnightLove
Endocrinology
I
49
According to C/O
ll Weight reduction ///,'+ O hyperinsulinemia & hyperandrogenism
2] If the main complaint is hirsutism
> COC.. ....containing 3ra generation 'P' e.g. Yasmin/ Gynera/ Marvelon/ Cylest
> Diane.....35pg EE + 2mg cyproterone acetate
6l lf the main complaint is irregular uterine bleeding
> Medical
- COC: 21 days -+ stop 7 days -+ repeat
- Progesterone
( Provera (medroxy progesterone acetate) 10 mg
( Prevents also end. hyperplasia d.t. unopposed 'E'
>D&C
- Therapeutic -+ if medical therapy failed
- Diagnostic -+ to exclude endometrial hyperplasia & malignancy
> Hysterectomy
- Atypical hyperplasia OR Endometrial carcinoma
- ln old patient -+ with failed medical therapy and DsC
4l If pregnancy is desired
> Medical
- Induction of ovulationf.*'
-Oral hypoglycemics ///
metformin (glucophage) 500 mg 1x3
( J insulin resistance -+ J androgens -+ spontaneous preg.
> Surgical ,"+ if failed induction
* Laparoscopic ovarian drilling
. 4-8 punctures in each ovary for 24 seconds each
. Advantages -+ less adhesions:- pregnancy rale70 %
WhiteKnightLove
I
50 ?frzrilrr" /,
Fu"i"eil ooo
H),pothalamic "+ tumors destroying the inhibitory pathway
WhiteKnightLove
........ .(eruexonRHEl -cAlllcrolRt{EA srruonorue).
{Mmrp
1. Treatnent ofthe cau8e
+ hypothyroidism or renal failure
2. Stop anycausafive drq
3. Brcrnoffipline (Padodel)
{{ + dopa:nine agonist o
* It is an ergot alkaloid
* Dose: 2.5 mgtablet twice daily
* Side effects:
. NaV + avoided by giving it
with meals or vaginally"
. Postural hypotension + avoid
by sradual f ofdose
4.fr
ver + satisfactory results (7s disappear spont. " )
* IndicaUons ofsurgery
. Tumor doesn't J in size with drugs
. Vision is affected (compression of optic chiasma)
.Intolerable side effects ofthe drugs
5. ffgot pregnant
* Continue dopamine agonists o (not teratogenic)
x Follow up the visual field / trimester
WhiteKnightLove
52 qqrzrnhrrl r4
& Lurenl PHAsE Derecr (LPD) h
Definltion
Inadequate progesterone in the luteal phase leading to
C 4% of infertility cases
C 35% of repeated abortions
€tlologV @@
1. Defect in CL function
- Normally in -+ post-menarcheal, post-delivery, pre-menopausal
- Reduced follicular maturation (I nSU & LH.....pit or hypothalamic)
2. Early degeneration (luteolysis) of CL
- Endometriosis (t PG-F2,)
- Hyperprolactinemia, Hyperandrogenism, Hypothyroidism
3. Endometrial insensitivity to progesterone
Traotment
o Prog. in the 2"d
'A of the cycle ocontinue by DMPA lM/wk for 10 wks if preg.
o HCG in the 2"d Y, of the cycle
o Induction of ovulation....*
- Clomid t HCG
- Clomid + parlodel or thyroxine or steroids
- Gonadotrophins + HCG
Pothogenesis
. Failure of rupture of the mature GF (probably due to PG imbalance)
. This is followed by luteinization of cells -+ progesterone secretion
. The resultant is -+ NO ovulation in the presence of ROEOURTE luteal phase
Dlognosis
- Tests for LPD -ve
- Follow up of GF by U/S -+ no collapse of follicle
Ilestment
Proper induction of ovulation * give high dose HCG at ovulation time
WhiteKnightLove
Endocrinology 53
1. skuclion by . Chemotherapy
. Radiotherapy
. Hysterectomy
2. ldiopothlc "+ commonest / (+ve family history)
- helped by smoking, alcohol, undernourishment-
3. bililoting diseose ,.+ pemicious anemia
o
4. Chromosomolu+Turner, trisomy 18 or 13
5. lnfections tr+ mumps?, TB
6. Autoimmune ,'+ anti-ovarian antibodies -+ lymphocytes & plasma
cells surrounds the follicles e.g. Hashimoto thyroiditis
DJognosJs
o Hislory -+ amenorrhoea < 40 yrs (take care ..... .pregnant? ...... !!) O
. C/? -+ of estrogen deficiency (as hot flushes)
.lnvestigotions
- FSH > 2540 mIU /mL (hgpeqonadotrophic-hgpogonadisrn)
- Chromosomal -+ Tumer syndrome
- Ovarian biopsy:
. POF -+ no follicles
. Autoimmune -+ lymphocytes & plasma cells
. Resistant ovary syndrome -+ normal number of follicles
LoEhogelasls
- Failure of the ovary to respond to pituitary Gn
- d.t. absence of Gn receptors in ovary or presence of antibodies
lnvestlootions
- JB + trsrr (hgper-gonadotrophic hgpo-gonadism)
- Ovarian biopsy -> normal follicles (to differentiate it from POF)
Treotment
- Spontaneous recovery may occur
- Induction of ovulation is vERY difficult (needs large doses of Gn)
- Oocyte donation (condemned?)
WhiteKnightLove
54 q4rcerohg r{
7 HYprnANonocENrsM
oo
O O androgen productioo ffij
qH
Erdude:
P@i
CrcFnos
dtut Md6
) Endogenous
C#drrydm
lfufu
Afusln.ffis
3. en sqqqes'Five of etiologg
CAH, and Cushingt syndrome.
) Excf ude,+ family his tory.... ....drugs ... .....thyroid function tests
) Testosterone level ,+
r If normal.... 0.2-{.8 nglml ......no further investigation (idiopathic)
r If testosterone > 150-200 ngldl (N: 20-80)...ovarian tumor. . . . . ..U/S
I If DHEA-S > 700 pgldl (N: 150-300)............adrenaltumor.......CT
) For etiology
r U/S + LI{/FSH ratio } 3 -+ PCO
r Serum prolactin -+ hyperprolactinemia
r Serum cortisol & serum DHEAS + Cushing synd.
r Serum 17cr- OH progest. -+ CAH
liroornend
t. Treatm€nt of th€ care e.g. Iaparoscope for PCO
OvARY
O Estrogen O Progest. (D Dexam- O Flutamide @ cnnn
ethasone analogues
receptor
t synthesis J LH secretion 0.2F0.5m9 /
(eulexin JovarianE&A
of SHGB + day
250 mg/day) amenonhoea
-+ J ovarian + OFlnasteride
(but leads to
J tree Androgen osteoporosis
suppress the (proscar) within 6 m)
androgen e.g.
adrenal gland
. Ptovera 5cr-reductase
ts, (10m9/d) , enz. (Smg/d)
- lasmlne . DrfipA sN
afoneru (150 mg /3m)
Olhers (importont)
o Androcur (cyproterone acetate) -+ progestogenic & antiandrogenic
o Spironolactone { { (aldactone) 25 mg /d -+ acts as androcur
o Diane + 35pg EE+ 2 mg cyproterone acetate
WhiteKnightLove
Endometriosis
Fibroid
Pelvic inflommotion
Uetrin polyps
WhiteKnightLove
.".FMOoDmrfEfaoCI[t A
Defloltloas
l) Cgcllc bleedtng
-
Menorrhogio (excessive amount I duration attime of menses)
-
Polymenorrheo (too frequent menstruation d.t. too short cycles)
-
Polymenonhogio (combination of the above)
9) Hcgcllc bleedlng
- Metronhogio (irregular bleeding unrelated to menstrual cycles)
- Menometrorrhogio
- lntermensiruol bleeding
Et rocatl oo
> eomplicatiaru ol puanancq.
o Earlg abortion, ectopic, V.M.
o APhgre - placental, extraplacental
c pphgre - atonic, traumatic, retained placenta, DIC
> ?ehie pqtfuW
1l@onqenltal d uterus didelphys / bicornis -+ menorrhagia
2ltrautmtlc d obstetric, surgical, direct. ......IUCD
3lgntlammatora O acute / chronic infection -+ ulcers & pelvic congestion
4l.Eumors O
- Cervix (benign + polyp 7& - malignant + carcinoma or sarcoma)
- Uterus (benign + fibroid 3096 - malignant + carcinoma or sarcoma)
- Endomehiosis & adenomyosis
- Ovary (neoplastic or non-neoplastic)
WhiteKnightLove
57 qrl.,crnlar" r,
* Dgsfunctional (functionol)
DrrrNrrroN
o Abnormal uterine bleeding in absence of obvious ORGANIC cause
o Due to
. Hormonal dysfunction (I{PO axis)......Metrorrhagia(80o/o of DUB)
.Local."jfi?"j[i1##ffi").......Menorrhagia(20%of D|IB)
* lr rxreRTrLITY
- HCG or clomid + HCG
- ART + if failed induction
WhiteKnightLove
frpvular facyc{icJ rrr+
2) Mictoscopic
- Endometrium + proliferative endometrium but no secretionso
- Epithelium -+ t treigtrt (cuboidal - tall columnar - crowded)
- Glands t No, sizn, dilatation (cystic glandular hyperplasia)
-
- Stroma -+ hyperplasia
. Ovaries
. Enlarged with + unilateral follicular functional oyst (<6 cm)
. No corpus luteum
> lnvestigation
- TVIIS + .... ..asrnMacpatholng
- DaC -+ ... ...as nMic pathahg
> Differential diagnosis
- Amenorrhea followed by bleeding (e.g. abortion, ectopic, V.M.)
- Irregular utedne bleeding (e.g. tumors, fibroid)
WhiteKnightLove
Menorhagia
Algorithm for
menorrhagla.
Hyn ro3coplc yLw of lntnutrlno polyp. An ffi.lt!.dm progaatog.o-rd.rthg r,5hm ln {r. ut rua
H@ter
Eise lluld
temptrature
--End(retrium
WhiteKnightLove
Endocrinology Sg
Treatment
L- eme,ul
o Corect anemia (even blood transfusion may be required)
o Anti-PG {/ e.g. Mefenamic acid, Ponstan, ibuprofen
o Anti-fibrinolytics e.g. tranexamic acid (cyklolapron)
o Haemostatics e.g. diosmin (daflon), ethamsylate (dicynone)
2- Shtmnnal
o lf Bleeding
,+ Progestins
- Provera l0 mgld for 2l
- LNG-IUS @!g) // -+ | bleeding 9\Yoin 1 yr o
,+ COC
- Once daily: 21 days -+ stop 1 wk + repeat
o lf failed
,,+ Danazol or Dimetriose (gestrinone)
',+ GnRH analogues
o lf infertility........induction of ovulation
3- Swaical
. DaC -+ diagnostic (ovular or not - tumor or not) & therapeutic,.,50%
o Hysteroscopic endometrial ablation 3
- ,+ .t generation.
1 .. .endometrial loop resection / diathenny / laser
,q fnd generation. .. microwave / radiofrequency ablation (ngyasud / / e
o Hysterectomy -vaginal, abdominal, laparoscopic-
"+ Failed all above measures to stop bleeding
,+ Associating pathology is found
*+ Old age
2lTnnrsnolo BmrorNc
> Etiology
Occurs at extremes of reproductive life due to waxing &
waning of estrogen levels which are high enough to stimulate
proliferation but not to maintain it
) Treatment
- Estrogen for 10 d. then -+ E+ P for 10 d. -+ repeat for 3 cycles
- lnduction of ovulotion if infertility
WhiteKnightLove
60 qqrealn q ri
g to Aowloea0 actioa--
o'V/itbdraual p+v)
- Normal menstruation
- After COC
o Breakthrougb
- E + metropathiahaemorhrg1ca
- P -+ injectable conftaception or Norplant
Nile: -.......---.
Day start:
xrlwy 2 3 4 5
mDltr 1 6 7 8 ,|
2 3 4 I
r:\ 5 6 7
!J I il
o
a I il ll NI il
I
t
ilt lil
-
:lob./ lp loP f,ot/
F
9 *laton{ugb
o Local ..............benign/marignant neoprasms, cervicar urcers
o Systemic........,.,irregular use of contraceptives, IUCD
o DUB........,...,.metropathia haemorrhagica
9 Contrct fite?f,tng
o cervicitis.........cervical ulcers (erosion)......cervical ectopy
o C1N...............cancer cervix
o Vaginal or uterine tumors bulging into vagina
o Severe vaginitis esp senile type
Contact bleeding is considered CIN
until proved othersdse
WhiteKnightLove
--- Ahnonta0 goalla0 &eeodlng aaaotdlng to ago --
Neonoutpeid
Slight bleeding may occur in the 1$ week + birth crisis d.t.
withdrawal of 'E' obtained from maternal circulation
Cffifiod......h
o Traumatic + foreign body /, sexual abuse
s Inflamm atory + Pre-pubertal vulvovaginitis,/,/
u Neoplastic + . Sarcoma bo@oids (cervix or vagina)
. Germ or Granulosa cell tumor (ovary)
o Miscellaneous -+ Precocious puhrty
L> eufiertt
o Dysfunctional utedne bleeding
o Coagulopathies $rWD)
Cfrihtie4rh,gpetut
o Complications of ptegnancy
o Complications of conttaceptio
futhtonoptltdt fititsrq....., h OO
o Dysfi:nctional utetine bleeding
o Otganic + incidence of tumots is increased (e.g. fibtoid, CIN)
futt 5bt&rg....... h @O
ttotopotlrot
o Malignant ttrmors of genital ftLcty
- The most setious but not the most cotnmofl (tisk is 10-20 oA
-Endometdal catcinoma. . ..cervical cancer.. ...others
o Benign conditions of genital tract
- Tumors -+ endometdal hyperplasia, fibtoids, polyps /
- Atophic Qeruile) endometrium ..../(ttt by HRT)
- Postmenopausal aftophic vulvo-vaginitis
o Complications of HRT or Ptolapse:-
- Ttophic ulcers
- Neglected retained pessalT
o Non-gynecological conditions
- Genetal. ..........hemato1ogic diseases, severe hypertension
- Bleeding / wethra......urethtal caruncle
- glsgding / tectum.. ....piles or malignancy
WhiteKnightLove
Thyroid function tests
Ckitting studies where
clinicalI indlcated
lnvestigating menorrhagia.
WhiteKnightLove
u ruse of ubnormul oenilul
bleetino h
> I{isto}g
o Age.
-
a Maital status........complications of pregnancy
a Present bist0ry........
,"+ Analysis of bleeding e onset, duration, amount, coc, ttt received
-
"':'T:i:ffif,?#y
;irl:r*""'
- Fever, pain , offensive discharge + PID
a Menslrual bbtor1.....to see if cyclic or acyolic
a Obstetric hitory......recent abortion (2o hge), recent VM (choriocarcinoma)
o Contractptiae ...,.....inegular COC intake, long acting injectabtes
o Pa$ history... ........ .hypertension, endocrine disease, easy bruises
> Exsmihetion
o Genral
- Anemia & its degree
- General disease e.g. hypertension" endocrinologicat diseiue
- Metastasis & jaundice
o Abdoninal
- PelviaMominal swelling (frbroid, ovarian tumor)
- Pregnancy
a Vagi*al + detect a local cause + P/R
> lnuestigqtion
a Bbod tests
- CBC, coagulation profiLe /{
- Organ function test (etiology or preoperative preparation)
- Hormonal assay (for DIJB)
- Tumormarkers
o Scanning
- X-ray (ches! HSG)
- U/S (abdominal, vaginal),
CT, MRI
o EndoscoBt + Laparoscopy, hysteroscopy, colposcopy
BroPg - Endometrial sarnpling
" -
Cervical biopsy
-
Vaginal cYtologY
WhiteKnightLove
qqernli4? r(
Cystoscopy if
hematuria suspected
WhiteKnightLove
64 qrlerrahq? ,4
(Poin roloted to menstruotion)
[reot'ne;i
lllledtcst //
> Anti-PG e.g. Mefenamic acid, naproxen, ibuprofen, aspirin
> Honnonal suppression of ovulation: COC
> Recently... glyceryl trinitrite. . ..vasopressin antagonist. . ..sildenafil
2lSurg,csl ,(/Y
> D&C -+ dilate the pathway & lacerates paracervical sympathetic nerves
> Presacral neurectomy (LIINA) -+ intemrpts motor nerves
WhiteKnightLove
Endocrinology 65
I
2. GoxcesrtvE DvsuexoRRHEA
[@g!Egqd
- Treatment of the cause
- Avoid constipation
- Glycerine icthyol suppositories * I pelvic congestion & pain
3. OTHERS
> Membranous dysmenorrhea
r Painful passage of large endometrial casts during menses of unknown etiology
r character -'.t",",:;:1?##:"1"
finffi#H:l"3 [l[ *ur-..,,,
. Followed byrelief of pain & increased flow
r TTT-+ suppress ovulation (COC pills for few cycles)
:llilHi::::::i:l:i#Hilfty,:?""j.,11":lg:"",%'"-
o TTT-+ reassurance t analgesics (inhibition of ovulation if severe)
WhiteKnightLove
ProaoarCrud rracrroao (PMS, PMT)
fncidence
o 50 - 80 % of females will report uncomfortable / distressing symptoms
o Severe symptoms occurs in 5 %o only + intemrption of social life style,
drug dependence (PMDD: PreMenstrual horic Disorder)
o Up to 60% wrth severe PMS have an underlying psychiatric disorder
o Presence of cycltc
sympt at luteal phase (.'. cycles must be ovulatory)
. ABSENT symptoms at follicular phase (i.e. relieved by menses)
o Physical & laboratory examination EXCLUDES organic pathology
. SyMproMS: (ny 150)
> flftUAi.al
- Mastalgia (pain & congestion of breast)
- Jointpain, muscle cramps, backache
- Abdominal distension, NsV, diarrhea or constipation
-
Waterretention -+ edema of face, LL, t body weight
> floyilalngical
- Depression, fatigue, headache, irritability, change in libido
WhiteKnightLove
Endocrinology 6T
I
Treotment
l. Generql
- Reassurance
- Depression + . Tranquilizers & antidepressants
. Psychotherapy for resistant cases
Antiprostaglandins -+ J pain
2.Diet
Increase sugar intake & decrease salt
Linolenic acid derivatives (primarose)
Encowage exercise
Diuretics: spironolactone (J aldosterone)
25mg1x3+JNaAnO
3. Mesfql[is
- Vitamin 86 @yridoxine) 100 mg + tserotonin & dopamine
- Dopamine agonists + parlodel or dopergine
& Hormones
;",';;;l
Jt":* ll [1"*n::,
llil*.,",
llll*"'r-,.r
rl
" , li;'l*l
l__lt_
lBtruction5 for complcdnE
WhiteKnightLove
etiobsy
Cs3es^vw",nU
1r"ot.nn
"rn
t
A = =L=L"
I re po rod.,."tlo rn
WhiteKnightLove
I
Et/rrecrh% r1
. Causes of infertility.
100
BO
_q
o
l
o
o 60
o
s
40
20
o 6 12 18
WhiteKnightLove
!nfertility 68
I
Inlottlltty
Definition
lrs idrrtilifu is INasrt,lry To CoNcErvE qfter 1 year of continuous
marital lifewithout use of any contraceptive method
> Incidence
\ lO - l5 % (incidence rise with t of aXe)"
\ N. conception rate: 20% Qm),60Yo @m),80% Qm), 90% @m)
O Imperfect spermotogenesis
. lv testicular failure... .........high FSHO
- Congenitol -+ sertoli cell only $, undescended testis, Klinefelter $
- Troumotic -+ direct (immunol.), thermal (varicocele + J motility)
- Inflommotory -+ mumps orchitis, syphilis
- Neoplostic -+ tumors destroying the testis
. 2v testicular failure (pituitary)... ...........row FSH O
@ Obstruction to tronsport
. Congenitol+ congenital absence of vas, cystic fibrosis, Kanagener$
. Troumotic -+ surgery (for hernia or prostate)
. /{ fnflommatory -+ epididymitis, funiculitis, prostatitis (chlamydia)
. Neoplostic -+ tumors of epididymis or prostate
O Foilure of deposition of sperms
. Anotomicol + h;rpospadius & epispadius
. Neurogenic + retrograde ejaculation (diabetic neuropathy & spinal injuries)
-+ interference with innervation (known by urinanalysis)
. Psychologicol -+ impotence & premature ejaculation
WhiteKnightLove
@ ?'v.12
- Regressing
corpur luteum
Doy 22
Doyl / '( Dav.28
Primordiol follicle -Eorly corpus olbicois
Abnormal pltultary/
hypothalamlc/endocrlne proff le
. PCOS
. Hyperprolactlnemla
. Hypo- or hyperthytoldism
Cannabis use
NSAIDs
Endometrlosis
Uterlne problem Submucosal flbrold
Uterlne septum
Asherman syndrome
Uterlne anomalles
WhiteKnightLove
lnfertility
I
69
@ Pelvic (peritoneol)
o Tn[ometri.osk(IE21%ofinfertility) ] DDof
o j frozen
"ID@rD
s Extensiye surgery ) pelvis
o Tube (20Vo),+ the commonest cause of 2ry / infertility
o Congenitaf. hlpoplasia, diverticula, accessory ostia
o lraurnatk ......surgeryonorneartothefube
o tnftarnmatory .....salpingitis/l
o Steoyfaxn .......broad lig. fibroid or ovarian cysts
€) Uterus (5%)
a Corgenitaf ................. ....aplasia, hypoplasia
o y'rantmatfu......................surgery ) Aschermon
o Inftammatory.. ....endometritis ) syndrome
o Steoyfasm... .. .... ...polyp or fibroid
o lvlisce[fane.ous.................prolapse & RVF + v. rare
0 Cervix (5%)
tr Congenitaf ......atresia (pin-hole os)
o lrattmatic ... ....cautery, cone biopsy ) poor hostile
a Inffamm^atory.... ...chronic cervicitis ] cx mucous
o Steoy[asm........ .....polyp ortumor
@ Vogino
o Cangenitaf.... .......atresia, septum
tr Trautnatic ...........previous surgery, stenosis
a Inftarnmatory . .vulvo-vaginitis -+ hostile to sperms
tr Steoy[asm. ...cysts interfering with intercourse
.
WhiteKnightLove
Toil tip-to-roil tip
WhiteKnightLove
I
lnfertility 70
Examinatlon of a man
Scrotum Varicocele
WhiteKnightLove
lnfertility 71
n $ssessmeot of infertility
...... Mole 0 is ossessed first ......
O Hsronv
, pororrl
o Age---------------testicular function declines gradually with age
o Marital status---If has children or not fit fromprevious marriage
o Address-----------rural areas (Bilhariziasis)
o Occupation------. Exposure to heat (bakeries, ovens) -+ thermalinjury
. Exposure to irradiation or lead -+ testicular damage
o Special habits----Marijtana, smoking -+ impotence
t C/O ,4, orry senital or uroloqical problems e.g. varicocele, urethral discharge
O lmuesrceroNs C'
> Semen analysis
Collected in a sterile container (& not condom)...after 3 days of abstinence
Normal semenog:am
. Macroscopic
- Character-:-----viscid, whitish, liquefles within % hour
- Volume------------2 to 4 ml
- Odor----------characteristic
- pH----------alkaline (7.? - 7.8) "
o
. Microscopic
- Count---- > 20 ,/ million /ml (60-120 @ )
- Morphology----- > 30% have normal shape
- Motility--- > 50% show fonruard motility after 60 min
- Pus cells------------less < 1- 2IHPF
- Antisperm Abs ----- -ve (MAR) mixed agglut. reaction
> If azospermia ,+ testicular biopsy
o If *ve -+ obstructive -+ vasography to know the site
o If -ve -+ testicular -+ l. chromosome analysis
2. FSH & LH (differentiates lry / 2ry test. failure)
-'orqcrorrh.'..iffi:ffff;Ii:]']fi lflg:1'o*,*o.rodenomo)
- Hirsutism
- Chorges in hoir texture,weight, hot/cold intoleronce (thyroid)
0 History suggestive o6tubal factor
- Previous PfD (fever, obdqninol poin, dischorge)
- Previous surgery
- Endometriosis (severe poin, bleeding)
f Hlstory suggestive of uterlne factor
- Hypomenorrheo (septic obortion, Aschermon)
- illenorrhogio (endometriol polypi)
0 History suggestive of cervlcal factor
- Previous surgery to cervix
- Excessive leucorrheo
- Chronic bocloche
WhiteKnightLove
> Personal
.Age------ very young + ovulation not yet established
. older -+ have less chance, so proceed rapidly for ttt
.llsrthl strtus--------less chance on longer periods of infertility
.Pslttg------------to determine if lv or 2ry infertility
.Address-----------------Bilhariziasis : tubal block
.0ccuprflon-------irradiation or heavy metals -+ ovarian damage
Spectrt hsblh......... ...............Personqt Historg of the Husbsnd
3. Endometriol Biop_gy
Premenstruo I endometrium is cleor evidence of on ovulotory cycle, but curettoge
or ospirotion is uncomfortoble lcor the potient, ond not olwoys feosible through o
nulliporous cervix.
WhiteKnightLove
OSymptoms suggesting ovulation
> Regu laritv / / of cycles. . ...spasmodic dysmenorrhea. . . .PMS
> Cervlczl wcus e) profuse, +ve Spinnbarkeit, rve fern. ...E effect
turns -ve on day l7-2L ..P effect
WhiteKnightLove
qrt.rrlogq r,
Ul6ru6 tull of
cfilEst agenl
Righl Fallopian
tube
(a) Hyslermalpinoo0ram conllmlng lubal patency; lhore is bilat€ral psritoml splll (b) Schematic represenlalion
WhiteKnightLove
I
(D Hvsterosalpinsographv
MeUrod + radio-opaque material is injected through cx & x-ray is taken
Advantages
- Oiagnostic......localizes exact site of pathology (uterus, tubes, peritoneum)
- llfurapeutic..,....Pressure during injection can break some thin adhesions
.I2 has antibacterial effect
@ Laparoscopv
relPru$!ry__
PCO & other ovadan for PCO, ovarian
cauterization of
Ovum pick up in IVF
@ @ycosy)
> llsthod - Injection of Echovist (a galactose suspension) via the cx
- The flow of solution is seen by transvaginal U/S
> Aduentage 4 no radiation, no anesthesia, offrce procedure
@ Tuboscopv
> Mathod - Falloposcory-+ trans-cx endoscopy oftube (via hysteroscope)
- Salpingoscopy-> trans-abd. endoscopy oftube (via laparoscope)
> Advonhge + both tubal anatomy..&..phytiology [mucosal cilia] are studied
@ Tubat cannulation
> Method - Transcervically, try to pass a catheter through the tubal ostium
- This is done guided by hysteroscope
> Advqhtsge <) bypasses cornual block
@ Older methods ,(
> Tubsl lnsrrffistlon (Rubln's tsstl - inject air through cx canal then do x-ray
> Kgmogsphg - pressure changes are recorded on a revolving drum
WhiteKnightLove
I
Dtqgmstrc Theroperrttc
Tubes r-glel hl_qq.k (qg99_9s
the -c-o_1pu
Any major pathology
Uterus
Tubes
Ovary
Uterus
WhiteKnightLove
> Ultrosonogrophg (Q..tlrttot ts Ere rrclue of U/S in tnferilliry?) (2
> Hystaroscopy (Q..tUhot ls the rroluo of hgsteroscopy tn tnferrille?) e
) PramonsBuol endomeHol biopsy
) Hvsterosolpingogrophy
oo
Ettotog of cr hogfiffig or -ue PCT *o
o Wrong time of cycle -+ Pr. effect or lack of adequate estrogen effect
o Poor glandular secretion d.t.
- congenital, poor estrogen response, cr.ouilo therapy
- Destruction of glands by cautery or amputation
A Infection + CgS from vaginal& cervical mucus
,\ Immunological factorc -+ cervical mucus (lgG) or in serum (lgM)
> Eperm wnetration tast (Done tf pcl ls -vef = 0x rnucous 0ontsct test
U Sllde test
. Cx mucus * donor healthy semen -+ detect abnormality in mucus
. Donor healthy cx mucus * semen + detect abnormality in sperms
2l Coplllory ube test
. Semen is put in a reservoir & cx mucus is sucked in a cap. tube
. The tube is examined for sperm migration after 30, 60, 180 min
WhiteKnightLove
Factom advesely affe(ting conception mts Preonception advice
Lifestyle
Female factors Male factors Combined factols
Stop smoking Optimire mnaBement of
Age (>37years) Low numbers Duration of mediel prcblem
of motilc, infertility Stop recrational Eliminate drugs not rfe for
healthy sperm (>2 years) drugs Pregnancy
Optinrire body weight to a
MenstLual FSH Dlug intake No previous body mas index of20-30
level (> l0 u/L) conception in Eliminate drugs not safe for
curtent Pregnsncy
relationship Regular uual Preprcgnancyffient
inlcr@uree, 2-3 tim6 by an obstaric physician
a week Commence folic acid
FSH, follicle-stimulating honnone.
supplements
Ensure immunity to rubella
Splint
r.;+I'
\I'i\
, Ulerus
Splint
, Ulorus
I T 't
rolrnosis
w6ll
WhiteKnightLove
> deneral .............,pcR- qq..............
- Correct Psycgoroctclt factors
- Correct Coner errors.. ..good timing
- RressuneNcp if the patient seeks rapid outcome
- Improve GBNsner health
- Treatment of any Gnoss pathology (fibroid) or local infections
> if ovarian cause
- Anovulation e.g. PCO -+ induction of ovulation....lap. ov drilling
- Hyperprolactinemia -+ dopaminergic drugs
. LUFS -+ induction of ovulation
. LPD + prog. in the 2"d 7/z of the cycle
- Resistant ovary syndrome -+ induction by high doses Gn.
Chrntd
Action
, Synthetic non-steroidal antiestrogen E
. competes with E for its receptors on pit. & hypoth. (hypo-estrogenemia)
-+ Decreased -ve feedback on FSH & GnRH
-tGnnu *t
rSH & LH -+ follicular development
o
Dose (Tab = 50 mg )
.7 x2 x 5 starting from the 2* (5*) day of the cycle for 6 cycles
. lf there is amenorrhea + give progesterone...withdrawal bteeding...then start
. If no ovulation -+ increase the dose up to S tab /day (250 mg)
o
Side effects
. Hot flushes, dqr vagina, breast tenderness, headache, visual disturbance
. Multiple pregnancy (5-10%)
. OHSS (Ovarian Hyper Stimulation Syndrome) -+ rare
' Relation to tumors ' ' '
i I'11 'i"H#.t f :fl,.?il & ,o anraeonistic acrion)
Results
s GmdresPonso (75%) known by
- Biphasic Body Temperature
- Mid-luteal progesterone
- U/S + folliculome@ (mature Graafian follicle : lB-22mm)
\ llo resDonee (CC failure or resistance) m.b.d.t.
- Another cause of infertility
'
- Poor cx mucous (anti-E etrecg + add small dose of b atovulation
- LPD + glve HCG orprogesterone
- LLJF + give HCG
\ ff fs,ld, nrrg rdd tho ftltortng
- Merprr,n -+ Or.u,y in cases with PnovsN insulin resistance in pCO
- Bromocrlpdne + even if the prolactin level is normal
- Tttyro)dn -+ in cases ofhypothyroidism
- Daemethasone + suppress adrenal androgen
- Natotrerorp (opioid receptor blocker) -+ opiods J Cnruf release
WhiteKnightLove
lnfertility 78
@ Antiestrosen + HCG
> Preparation
c Pregnant urine -+ Pregnyl, Profosi (IM)
o Recombinant DNA -+ Ovidrel(SC)
@ CnRA rLHTHJ
) Dose ,'l
ev€ry 60 - 90 min for 2-4 wks by:
\
a special pump (IV or SC). . ..OR.. ...nasal spray y'
> Adu ,,* uS€d if ovary is resistant to induction
> Disadv,* expensive & difficult
WhiteKnightLove
Eqderaln% r,
(a) Ultrasound showino stlmulated ovary with multiple follicl0s and associated blood supply. (b) Sdromatic r€presentation.
Ratc
wenLc, includa
'warianrupWrcwil,}],
lwmorrhaqe and adull,
raaplraroty Aibt cbg
oyttdrome., ?leutal
(ARDe) \:-._ cl'l\tEions
:\a aite6
Ovarian
Oli6rria, cnlarqefianl
cledttolyla >12 cm
imbalanoc
'llromDo.
anbolism
WhiteKnightLove
tDathoEeoesls
Cllnlcal plcture
1. Mild form + ovarian enlargement without cyst fonnation
+ abdominal discomfort
2. Moderate form + ovarian enlargement with cysts < l0 cm
+ abdominal pain, NaV, diarrhea and weight gain
3. Severe form o + as above but cysts are large
+ . hypovolaemiq hlpotension, oligr.uia
. haemoconcentration + DVT & embolism
. J renal perfusion -+ Na & ffrO retention -> edenra,
ascites, pleural effirsion, hyperkalemia & acidosis
(reatment
> Pmphglodc ,'t avoid HCG injection if - serum E2 is > 2OOO pghnl
- 2 3 follicles each Z 16 mm
> tlfid foitn '.+ no treatnent (rest at home * frequent follow-up)
> llodents & ssvsla ".r HospITarZATroN (even in ICt) +
l. Complete bed rest + no P/V (to avoid ovarian nrpture)
2. Analgesics for pain, anti-histaminics, anti-prostaglandins
A Hukl & sats rcotrlcfion to rcdue ascltes, hydrodrorax
t
- No diuretics (f hypovolaemia -+ haemoconcentration)
- Fluid chart to monitor intake & output
- Paracentesis or pleurocentesis (in resistant cases)"
? Follow up of
- Vitaldata (P, T, BPr)
- Hct, BUN, creatinine, coagulation profile, ECG (t K)
- U/S to follow the decrease in size of ovaries
WhiteKnightLove
Egg collection
WhiteKnightLove
O Glo {Iltro cFecillzadoo e, tsobwo cfransfer -lVF& ET-
> lndhstlons
o Tubes -r damaged or absent
o Peritoneum + dense adhesions e.g. endometriosis
o Hostile cr (e.g. antibodies or infections) -+ after failed IUI
.Unexploined infertilitg "
- Mole infatllity + d.t. severe OTA (only fewthousands are needed)
> Te$nlque
l. Superovulation,+ multiple ova
- Down-regulation by GnRH o (inhibits ovarian fimction < induction)
* Lonq protocol.,....starts day 21of the previous cycle
*Short orotocol (flare up)..,.starts with the
same cycle
- Then give: different protocols of HMG -+ folliculomety follow up
- Then give: HCG IM + complete ovum maturation within 34-36h:l" "
2. Oocyte (pic k-up) retrieval,+ transvag inal U I S /
.,,:.::i: g.Fertilization invitro
- Ova are incubated in a culture medium at37oc for 4-6 hours
- Then prepared sperms are added for fertilization.
- Wait till the fertilizndegg reaches 4-8 cell stage (takes 48 hrs)
4Embryo transfer
- The fertilized eggs are injected into the uterine cavrty near firndus
- Transfer (acc. to age)2-3 embryos b l, %of multiple pregnancy
- The remaining embryos are frozen (cryo-preservation) for later use
g.Luteal phase support "+ progesterone or HCG
> Resulh
. The procedure is repeated for 3 or 4 successive cycles
. -
The pregnancy rate is 20-30 % Q5 yrs) l0% (40yrs) per ttt cycle
. Multiple pregmncy occurs in about 35%
. Ectopic pregnancy occurs inabolt3 %o
O -etFT-
> Omgte & cperrns are placed into the fallopian tubes either through:
(
Ampulla (via laparoscope) or Isthmus (via hysteroscope)
> Ruulh ,+ 3}Yopreg. rate (better than IVF but with > ectopic)
O -ilrr-
> The fertilized oocytes are placed into the tubes as zuEdes
WhiteKnightLove
hlrq[oplasmlc spom lnlstion.
Uterur \,.
WhiteKnightLove
I
lnfertility 81
U@-@sg=ila-seuoits-at8@rn-
$nclications
* Arliflciol inseminotion husbond (AIH)
! Coital factor (failure of deposition of semen in the vagina)
' Male infertility (OTA)
. Cervical hostility
' Unexplained infertility
* Artificiol inseminotion donor -+ in sterile husband (unreligious, unethical)
Technigue
l. Induction of ovulation
( Better results when AIH is done with induction of ovulation
( Better results with gonadotrophins than clomid
2. Processing (preparation) of semen
- Anti-PG. ..........as it -+ uterine cramps (expulsion of sperms)
- Anti-biotic..... .. ifpyospermia
- Proteolytic.... .. ..........J viscosity
- Caffeine, Kallikerine... . . asthenospermia
3.Injection of 0.3 - 0.8 ml intrauterine (IUI) bV special catheter
WhiteKnightLove
*.,
Ji,
Tgstoslerore
LH+
a;\
( @tt
)
Fl0w diagram illustrating the relationships oflhe
hyp0lhahmo-pituitary-.te61irular uis. (LH, tuteinizln0
hormonei FSH, iofid}stimulating hormone; LHfiH, luteinizing
hormonB-releasing hormone.l
WhiteKnightLove
I
lnfertility 82
-- 1[xtras --
Historv
o lpulseBrcxrtn 11't IVF bom child) 1978 has gone her own baby naturally
. Edurards + Stemoe (British) won Noble prize (2010) for developing IVF
Causes of sterilitv
o Female -+ POF.....absent ovaries (Turner).......uterus (M. agenesis)
o Male + Klinefelter syndrome.. . . . . .. . ...absent testis (Mumps)
WhiteKnightLove
WhiteKnightLove
Ror*ingof corfiwefltirc meduds by
rote ofeftrtir,eness
Fallurc ratea
per l00HrrVY
GroupA l,lortefiectire
Tubal ligation/vasectomy 0.005-o.04
Comtined oral 0.00H.30
Sequential oral 0.20-o.s6
Group B Hlghlysfrcdte
IUD 0.5-3.5
Continuous progestogen t.5-2.3
Dephram orcondom anC cream
All users 4.O-7.0
Highly motivated t.5-3.0
Fariodk abstinence
All users t0.0-30.0
Highly rnotlwted 2.5-5.0
GrcupG ls.€ftc(lv€
Coitus interruptus 30.0-40.0
Vaginal foam or cre:rm 30.0-40.0
Grorp D l,eesGeilhcthrc
Postccial dotrche 45.0
Prolonged breastfeeding 45.0
WhiteKnightLove
I
Gontraception 83
> Hormonal
Combined (E + P) ,+ OCP,....monthly injectable.....,..vaginal ring....,...skin patch
Progesterone only,+ POP..... injectable (DMPA)....implants....Pr. releasing IUCD
> Non-hormonal "+ l.physiological,Z.barlier, 3.chemical, 4.IUCD, S.surgical
WhiteKnightLove
I
q,cltarnln% rl
5
NO
doys
No n.htltloilal cofrlfceptlot nec-
er&ry
988
986
o
c
c
984 o
c
6
I
982
980
WhiteKnightLove
I
Contraception 84
" Calendar method d ovulation occurs 14 d < the l't day of the next cycle
. I.C. is avoided 2 days < & 2 days > the calculated day
. Ovum lives -+ 24hrs / sperms live 48 hours
" Besal bodg tempereture O l.C. is only allowed after owlation has
occurred by 3 d, i.e. after 3 d of rise of BBT
n Ceruieal rnueus method a l.C. is allowed only after 3 days from
'Billing's method' disappearance of wetness
- €sLrogon +
profuse c( mucous +
ru@t sensoEion
- efter ovuloEion, CL -+ progesEorono -+ dryness of secretion
o
- The aest is combinotion (sgmpto-thermol)
WhiteKnightLove
I
qr/rurnlnf/ /4
Spermicide
creom ln-
iected into
the uppcr
vogino.
i
))
Z,
rdom,
WhiteKnightLove
Contraception 85
I
SF
15 x 3.5 x 0.02-0.07
r No side efiflects or contraindications
. Non contraceptive benefits -+
- Protect against STD ", PlD, CIN
- Treatment of immunological infertility
- Collection of semen for semen analysis (spermicide free)
2l Female condom (vaginal pouch)
. A polyethylene rubber sheath which lines the vagina (17 x 8 cm)
. Has 2 ends # a closed end and an open end
4l Ceruical cap
. Applied directly to cervix (22-25-28-31 mm)
. Used if there is prolapse (diaphragm can't be applied)
" Method
- Spermicidals -+ Nonoxynol-9 & Octoxynol-9
- Action -+ destroy sperm memb + J Oz uptake
Disadvantages
WhiteKnightLove
I
Gontraception 86
Most commonly
-Cu7 CuT200, CuT220 CuT3806{{ !10 yr
- Cu T 3806, (+ silver)
used now are-+
iess pain & bleeding
- Nova T
Multiload Cu250, Multiload Cu 375
l{tfi progesdru (levonorgesterel "; LNG-IUS
-better pregn. protecti
* Progestasert ) most recent
lyr
5yr
n Mirena" Icvonova
) but expensive "
o Mode of action
o
1- Aseptic endometritis -+ histological changes in endomet. -+ hostile for fertiliz.
2- Uterine & tubal initability (t pC) -+ interfere with sperm & ovum transport
3- lf + Copper
. Inhibit sperm o -+ affects motility & capacitation
. Inhibit implantatioz + affects endometrial metabolism
. Inhibit zygote + affects carbonic anhydrase (necessary to remove of COz)
Adv of adding Copper + it allows use of smaller IUDs (without loss of their efficiency)
Adv of addino Silver -+ it orolonos lifie soan of IUDs (bv orevenUno Cu
4- lf + Progesterone
- Atrophic endometrium
- Thick, scanty, viscid cervical mucous (prevents spenn ascent)
- Prevents spenn capacitatio
a Advantages @
r One decision method & cheap
'. Left for long periods & reversible on removal
No systemic effects & no interference with intercourse or lactation
'r Reliable (failure 1-2 /HWY " ). .....(0.2 in Levonova)
Non-contraceptive benefits of utG releasing intrauterine s,6tem (lUS) e:
- Treatment of dysfunctional uterine bleeding
o
WhiteKnightLove
I 87 q.laerrln q r4
e Contraindications (mainly local)
llfrreots
.
Pelvic infection (PID) or previous ectopic
r
Immunosupression, steroids, DM, RHD (fear of IEC)
Cu** o Wilson disease
! Amenorrhea + suspect pre gnancy
'Unf,wgrusa I
Bleedine -+ suspect malimancy
Complications 7P @a hh
7l E0oadleO
> ?eb'lnser|lon e?ohq-+ reassure
> lhenmiqta or ne*on*taqla (25-50 % I )
o lEtiofog1-+ mechanical irritation of endom.
(Treatment
- t pC & fibrinolytics
o
- Exclude pathology l't /
- Anti-PG & anti-fibrinolytics (tranexamic acid)
- If persistent -+ use a smaller or medicated loop
- If still persistent -) use another method
2) Pain
>?otb'tneerblon (* v66ragal attack) -+ exclude perf. then reassure
>?q;menartea
o Spasmo[ic f,1smenorrfi.ea is only accepted
o Otfrerwise e4c[u[e -+
Lar ge device, expuls ion, perforation,
infection, abortion, ectopic pregnancy
3\ PTp
o lEtiofog1+ septic technique during insertion (throods octs os o lodder)
\ risk is slight o: esp in the l't month (octinomycosis isrooli E )
o ?ropfr,-+ aseptic conditions, cut threads short (difflculty in removol)
o I(TT-+remove IUCD (1" step) + strong antibiotics (oc<. to C"S)
>Vaginal disch / backache are common (pelvic congestion / <hr cervicitis)
4l oxPa0sloa
o 50Yo occur in l't 3 months; esp during menses
o 8[f I If insertea fo.pu.t* / fregnancy occurs
* Too large ltoo small / bad technique on insertion
* Local abnormality of uterus / cervix
o Y__gytg
"_g9
1 ryllfparity
WhiteKnightLove
o
5l Patotdtott (rare )
o cP[f -+ satne as above y'
(mostimpisthereluctance/overconfidenceofthedoctor)
o Sus7tecte[ f,uring
- Insertion -+ severe persistent pain & vaginal bleeding
- Gradual perforation later on leads to:-
. PID (2'r')
. Mssedthreads
o *tarugamm, + as in missed loop
6l Ptoerurcv
> lnbrahqtrv,+ i.e. failure (1-2 /HWD
o Due to..... ......misplacement, perforation, expulsion
o Presents as.. . . . ....... .omenorrheo + B-HCG + U/S
o There is risk of........septic abortion, PROM, PTL
o Management:-
- If tfrrei& accesi6b-+ remove " ...........25 %iskof abortion
- If not accessifib + continue .......50 Yonsk of abortion
(with t o/o of sepsis but no f inW of CFMF)
> Ex*ah*ttc'* i.e. ectopic (l-2 /10.000)
o lEtbhgy
- Associated tubal infection
- Decreased tubal motility (as in mirena)
- Good protection of intrauterine but not extrauterine preg.
** Some say -+ ILID I ectopic i esp Cu T 380 A/
\ as it I the overall rate of pregrancy
o futatugunmt-+ as in ectopic pregnancy * remove IUD
WhiteKnightLove
E7rrailn rl
"
PRINCIPLE OF INSERIION OF lUDs
JT
)'iq
ii\
.'i'
WhiteKnightLove
a Technique of insertion c
8 Cowscttfie ptintfu
o Tlpe / duration of IUCD
o Failure rate
o Warning signs 11
.....Missing threads / period
.....severe pain / discharge / bleeding
,ffig
o Post-menstrual (cx is somewhat patulous, sure notpreg.)
o Post-abortion (by one week)
o Post-partum (1't 48 hours or after puerperium)
o Post-coital (emergency)contracepion
tl gteefiotism
o Anesthesia .....no need (ust 2 supp. anti-PG)
o Position. .........lithotomy
o limanual examinauon........size, position, any contraindication
o Cusco speculmr. ......sterilize cervix by antiseptic solution
o Grasp arrterior ox lip.......vo1sellum
o Uter{ne souDd.. ......length & direction of uterus
o firyo different techniques for insertion of [UCD:-
Ilv p*'af,Lednt4n
- Used for inert devices as Lippes loop
- The inserter tip just passes the internal cervical os and the
piston then pushes the device inside the uterus
- The nylon threads are then... cut 2-3 cm...fromthe cervix
Ilv wtlMrau d +edmt4.le,t,t
- Used for copper devices
- The inserter is intoduced to reach near uterine fundus,
then the outer sheath is withdravrn externally.
- This technique. ..reduces...rncidence of uterine perforation
3l ,fotow ttp .The patient is examined after the nqt menses & then every year
.Self exarrination after each menstuation to feel threads
tl tntru*rc ofmovat
o Whenpregnancy is desired
o Ifpregnancyocour
o If complicatiorxi occur
o Each device has a certain Vzlife
o After menopause (usually by one year)
WhiteKnightLove
Co m bi ned oral contraceptive pill preparations.
A
t75
150
Norrnalcycle
125
100
75
50
2.5
0
/,,L
2 4 6 I rO1214161820222426
Days
B
150
125
r00
75
50
25
WhiteKnightLove
.t, l. COC pitls .!}'
> Composltloo
E. used +. Ethinyl estradiol or
. Mestranol (Methyl EE). It has Vz potency of EE & requires
removal of the methyl group in liver
P. (gestagen) used a similar to testosterone
o
) l* genorotlon
o ESTRAN€ ....Nolesthisterone,Norethindrone,Norgestrel
o PR E GNA NE ...... ..Medroxy progesterone aEBtatE
) 9d genorotlon: Levonorgestrel
) 3'd genorotion: (new progestins) : t potency + J androgenic side effectso
o Desogeshel... ....,1Tlattelone
. Eestodene...... ....danera
. Norgestimate.... ..eibs!
) 4s generotlon: drospirenone.... ....Uasnat
> {-lmes
O monophasic,,+ all pills contain same concentration of E+P
according to E content -+ may be:
- High dose: 50 pg EE e.g. ovral
- Low dose: 35/30120 ytgEE e.g. microvlar, norminest
O Biphasic "+ all pills contain E + P but pills taken last 1l days in the
cycle have double P concentration e.g. binoyum
WhiteKnightLove
' Mon
@
PREGA
J-
v tloE than r F>.
12 hours lele v
. DEcard arry oarll€r
dseod plb
. Ulo o(ia P|uutbn3
(oorxbm, hrhsbte)
tor hs nd 7 (hy8
fl
tl
il
V
How many dL aI€ lelt
lr' - :r ln emost
,, ,'''
il
J.
7 or morg
plls
flv
Wh{youha\rllhbhod Whenyouluro
he paclq leeyg tio ueral [nEFd the padq Srt
rurybmal b€6lr otarhg 0le rFxf pd( ne((hy,
heDodpack ntfioutaboaft
WhiteKnightLove
> -Sdvanta€es (DO
* Controceptlon
- Failure rate :0.1 / HWY (most effective method)o
- Cheap, easy to use, not related to intercourse, rapidly reversible o
>@-
Choloe of pills -+ better to use
- Low dose E pills (less E side effects with same potency)
- Triphasic pills (more similar to natural cyclic changes) i
- New (3d generation) containinl pills (less A side effects)
Stailing pills
- From day 2-5 of cycle one tablet is taken daily for 21 days then
stop 7 days + menstruation (after 2-3 days). Then repeat
- May start fromthe ls day of cycle + better protection
- The 2Spackcontains 7 days ofiron(norminestFe)
- May start 4 week after labor (non-lactating)
\ or I week after abortion
Missing pills
- If 1 pill is forgotten + take one as soon as possible then the
next pill is taken at usual time
- If 2 pills are missed + as above but
\ exta-precaution backup for the rest of cycle (e.9. condom)
\ if < 7 pills are remaining in the pack + start another pack
next day...(thus omiuing the usual 7 day free interval)
Drug interactions
* Drugs + J pills " (sedatives, anti-epileptics, anti-histaminic, antibiotics /)
* Pills -+ I drugs (anticoagulants, antidiabetics, antihypertensives)
WhiteKnightLove
$tde effects g Conplicatlons h
> CNS [P effect]
- Headache & nigraine
- Mood cbanges -+ depression & irritability
> gg!
- ,E, ffirt -+ liability to thrombosis / (effect on clotting factors)
- P effect . Astherosclerosis (effect on lipid profile)
. Hypertension (salt &grOretention & t renin-angiotensin)
- Amenonbea
- Exclude pregnancy (P-HCG + U/S) then + start pills after 7 d
- If persistent for 2-3 months -+ pos@ill amenorrhea
- Spotting
- If occasional + reassure (inappropriate hormone content of the pill)
- If early + use pill with more estrogen
- If late -) use pill with more progesterone
- Also may take 2 pills forrest of the cycle
- Breakthmryb bkeding
- Stop pills 5 days then restart (+ backup contraception for 2 wks)
- Or use pills with more estrogen
- Change in libido /I*uchorrhea(pelvic congestion)
> Skin
- f n;gmentation -+ chloasma [e' +P1
- Acne, birsutfun -+ recentll inprowd " (with 3d generation e.g. Diane)
WhiteKnightLove
Cor*ralodlcatloos (qfiu ohtz. . ..ar,. . ..,rclnrrul
> cNs
. Migraine
' Epilepsy (COC + decrease anti-epileptic drug efficacy)
o Otosclerosis
o Optic neuritis & glaucoma
. Porphyria
o
t+
> !4g]g!lon @...............4bs01ute#
> Egr
. Mmkedly impaired liver function, history of cholestasis during
prggnancyr adgnoma ............ o............. o...Abgolufg #
' Hyperlipedemia @ + increases triglycerides)
WhiteKnightLove
+ 2. POP (Minipitls) 'f"
Preporoiion
Pills containing very small amount ofProgesterone
+
o Levonorgestel Microlut (30 pg)
o Noresthisterone;p Mcronor (350 pg)
o Lynestrenol Exlutona
Mode of oclion
, On oervical mucous -+ thick //
I On endometrium -+ atrophy
. CIr speflns + inhibits capacitation
. To less extent -+ alter tubal motility & suppression of ovulation (50%)
Indlcollons
1. I-actating
2. ,4: thm ir no atmgen side fficts:
- [VS.........Liver
- 0ld'......smoker o
3. Ar thm * nin. Prog. ,fttt (rg.CHO, lipid netabolisn, weightgain)
- Diabetics E hypertensive
- 0hese
Conlrolndlcollons
- Undiagnosedamensrrhea
o
- Undiagnosed genital bleeding
- Previous ectopicpregnancy
WhiteKnightLove
"$ 3. Injectables "f"
lndicollons
l. Lactating(with no in caneer breast) t
2, At then b no eshogen sifu fficts:
- [VS.........Liver
- 0ld "......smoker "
Dlsodvonlooe & slde efrecls (D(D
t Can't reverce contraception once injection started (may take up to 9 m)
. 1 Risk of o$eopowtis f used in.ltoungerage o (reversible)
. As tbere is Prug. efet
- Weight gain in some patiEnts E
- Few metabolic effects -+ mild anti-insulin action. Decreased HDL-[
-
Amenorrhea + TAYoby the end of l$ year
-
Olieomenorrhea / h).pomenorrhea -+ reassure
-
lreeular bleedine + exclude pathology then give:-
::::: : : :1"Ift'.f,l:i*:*#:T#il'J#::Tfffi ;: :-
WhiteKnightLove
WhiteKnightLove
& 4. Subdermal fmplants +,
ilethod (Norplant)
- slx cylinders containing Levonorgestrel o (36 mg / cylinder)
- Inserted SC on inner aspect of medial side of arm in a fan shaped manner
- Slow release of progestin + lasts for fiwe years
WhiteKnightLove
q/rczriln% rl
cD
. A-D:The Pomeroy method of tubal neriliation.This technique is typically perfomed durlng the lmmedlate post-
partum perlod through a small subumblllcal lncislon.
WhiteKnightLove
33 Tvpes
1) Male,'+ Bllateral Vasectomy
.
Done under local anesthesia ) v. easybut
r
Use another method for 70 days ) not
.
Efficiency confirmed by 2 -ve semen analysis ) inEgypt
2) Female,"r Tubal tJgadon
t La?awscW / electrocoagulation of tubeorapplication of a Falope ringor clip
. Minila?aytonJ resection ligation of a part of the tube (Porwnov method)
t Poslbartum
- At C.section (common)
- After VD (2-3 days later via a small sub-umbilical ineision)
3t lndlcotlons
-
( permanent contraception:
o Completed family, old couple (> 35) -+ with failed all other methods
o Contraindication for pregnancy -+ v. weak scar, v. serious illness
8t Conlroindlcqllons
( as reversibility is difficult:
o Young uncertain couple with marital or mental problems
33 Compllcotlons
o Co@lications of anesthe$a or rffiXery (infection, bleeding bowel injury)
oPresnanE-K:::A;:r#;Jr.ffi
ffi:rargevasculartube)
- Faulty technique
o Post-ligation yndrone e
Menorrhagia & congestive dysmenorrhea months or
years after the procedure. Mostly due to interference
with ovannx venous refurn + congestion
$lale cootracefiloo.@ *
fuimonent r+ vasectomy
Tompolwy,+
> Physiological.......... coitus intemrptus & interfemoris
> Mechanical............male condom
> Chemical. ..............Gos sypol (inhibits mitochondria & motility)
> Hormonal..............progesterone I danaznl / LHRH analogues
> Imm u nological....... contraceptive vaccines against spenns
clmmuoolo$lcal cootraceptloo #
> Antibodies (passive) or antigen (active) for
) Sperns I zonapellucida IHCG
WhiteKnightLove
98 E f.zrilng? /4
9ostpartum contraceptlon @ -:N,
> Immedlate[
\
Breast-feeding, Barriers, sterilization
> lnctoting u,omen irt 6 tr,Ks
\
Progestagen only methods (POP, DMPA, implants)
\
IUCD
> lnc-rating u,omen at 6 momhs
\
Methods containing E (COC, combined monthly injectable, VCR)
> Mochonlcol
o IUCD is inserted immediately even up to one week o. FR: 1 %
o ltlensfual aspiration -+ suction of the uterine contents by Karman cannula
POP
Baniers & sterilizaUon are avaihbb offier for all
DM risk of PID
Cardiac X risk of IEC
maIIled
FJdeily (>40)
WhiteKnightLove
Gontraception 99
WhiteKnightLove
ogtrn ol ll."L'.r?!e
S"rrrlly tto^*n.,. LLL"I lirr"or"
\JdrovagtrrLtL=
C"ruLcltls
FdrL" Lrn flavwvwrtory llr"or"
CLron Lc gro.n n [or.^.oto w. ll=ea*e
WhiteKnightLove
I
Elrcaik% r4
Q +Ve G -ve
Aerobes Lactobacillus E-coli
Staph aureus, strept Klebsiella, proteus
Enterococcus faecalis Enterobacter
Diphteroids Pseudomonas
Anaerobes Peptostreptococcus Bacteroids
Clostridium Bacteroids fragilis
Lactobacillus Fusobacterium
Gardnerella vaginalis
Yeast (candida)
Nrfldvogir'r/ frou
OrSllLm Fcrc.nt gr
lactobacilli 8G-90
Staphy'ococcl,micrococcl 50-70
Urerrp/rr;mo ,rc-50
Anaerobes 20-50
Streptococci 20-30
@dnerClo lG30
Edi 5-15
Conddo spp. 5-15
Soctemltes LlO
Irkhononos 3-7
WhiteKnightLove
I
lnfection 100
Yrrrnrr aurcDrlt
o
trUclffhtd is clearmucoid (non-infected) vaginal discharge d.t. excess
of normal secretions. @g.leucorrhea means ony
abnormal discharge from vagina except blood)
Normal vaginal discharge 1
SflJKI
vtlvA Bartholin eland * Skene's
glands
vActltA Serous transudate + Barttrolin + cx mucus
(Rvtx (T*byE'-@)_.
UIROS _sp
j99l9l9lJ_pbgs_e)_
lrrEs Goblet
bacteria .abalance of
- Lacto-acilopfi.ifus fiacitfi// (Doderlein bacilli, gtve rods)
- $trept,, stapfr., lE-cofi
- Can[i[a, tricfromonas, mlcoptasmn, g-ge on4ero6es, {ipfrteroils
al defensive mechan
yagjna ffily by the 2 labia(opposedo )
-
o
. Lined by thick stratified squamous epithelium
o
. Acidic media -+ hostile for organisms (lost by O+O+9+intercourse)
Cervix + closed mechanically by a mucous plug
Uterus -+ monthly shedding of superficial layer of endometrium
Tubes -+ movement of cilia towards uterine cavity
WhiteKnightLove
I q.fianln rl
"
Algorithm for vaginal discharge.
Age
Sexual history
Odor/irritation
Urinary symptoms
Tachycardia
Fever
Abdominal tenderness
Cervhal motion
Pelvic tendemess
Microbiology swabs
Clean catch urine specimen
Laparoscopy
Ceur of dlrdn6c
Mlcroblologlc swabs Wet mount
Candlda alblcans
Trldtomonas vaglnalls
Bacterlal vaglnosls
Endocervlcal/urethral swab
Chlamydla t*homatls
Nelserla gononhoeae
Clean cakh urlne
speclmen
Pelvlc mallgnanry
WhiteKnightLove
I
lnfection 101
.9 AccoRDING To souRcE M
t. True leucorrhea (t"d normal secretions or transudation)
(esp estrogen)
. Puberty
. Premenstrual & midcyclic
. Pregnancy
. Puerperium (lochia alba)
- Pelvic coNGEsrIoN (constipation, coitus intemrptus,
sexual dissatisfactisn + pelvic pathology)
z. Patholoqic causes
- True leucorrhea
- Monilia - Bacterial vaginosis
- Endometritis, pyometra
- PID, P. abscess if opens into vag
. Foreign body
. Vag., cx, uterine -+ .Infection -+ p. sepsis, p.abscess
ulcers, erosion . Neoplasms -+ infected tumors
polyps, cancer . Fistula -+ fistula
WhiteKnightLove
q/r&i(nf? /4
fuu|c of s!reod of nG
Secondery lnfection
gnxred ord gonorocal n@im.
Adts elplngids
Pyosrlpinx
Pclvlc peribnitis
Prlmay infectlon
Crypc of odeewix
Pelvic abGcess
Sk re's obuls
EXAMINATION
The lobio crre held oport, ond the ureihro,
Skene's ducts ond Bortholin's ducts exomined for
signs of infect
for specimens
fronr th: cerv
infection "
WhiteKnightLove
I
lnfection 1O2
> Etroloov
Cause -+ gonococcus (gram -ve intracellular diplococcus)
Transmission + sexual intercourse......incubation period: 3-7 d
> Cttucal PtcruRE
Primary sites (V) a O Skene's glands & urethra
O Bartholin gland
O Endocx (angry red cervix * mucopurulent discharge)
\ the main reservoir of organism
other sites d
3 i}:qo.;|#i,fTj:xH,l,ffi onj unctivitis in adurts
Spread
o Local -+ .Vulvovaginitis (only prepubertal or postmenopausal)
pelvic or generalized peritonitis
. PID,
. Perihepatitis -+ Fitz-Hugh-Curtis (FHC $)
o General -+ septic arthritis, meningitis, endocarditis
WhiteKnightLove
r E4/4aco,/n q /4
WhiteKnightLove
lnfection 103
I
) Serotvpes (15 ?D
9 A B, C.........Trarl1t,prb
$ D-K..... .......9(y'/6lib€16 the corr/rmonest " flJD r/
u On 9 ,+ cervicitis, Bartholinitis, PID (more insidious / worse course than G)
o On pnncNeNCy'-r abortion, PROM, PTL, intrauterine infection
s On newborn tr+ ophthalmia neonatorum, pneumonia
u On d ,+ urethritis (sterile pyuriao), epididymitis, conjunctivitis
9 L l, L2, Lr..........@figtr anfirlot+1s aerugr clim
o Vulva, vAGINA, CERVIx ,.+ single or multiple papules, vesicles or
pustules + ulcers -+ fibrosis, stricture & fistula
o LvtvlpgapENoPATlry (bubo) ,.) suppuration, matting together, sinuses
o Crnouc LYMPHANGITIS ,4 obstruction, edema, fibrosis, elephantiasis
o Pnoctocolmls ,+ diarrhea, fibrosis, strictures & fistula
) Investigations
- Sm.ear -+ intracellular inclusion bodies + >10 pus cells / oil immersion field
- Culfiire + on tissue culture @ggq$.. the most reliable (but takes 0 )
- Antigen detedion -+ . ELISA ... .....the most rapd
. PCR -using NAAT technique-. . ... . ..the most expensire
- Serologg -+ micro-IFT", CFT
-
> Treatment CDC recommendation
WhiteKnightLove
'Clue celb',seen in Bocrerio, vdgi4iris.
WhiteKnightLove
I
lnfection 104
Gardnerella vaginalis
(Haemophilus vaginalis)
> DertrurtroN
Bacterial vaginosis means replacement of normal vaginal flora
(Doderlein bacilli) by other bacterial colonies (mainly
G.vaginalis, mycoplasma" hominis, ureaplasma urealyticum)
o
lncidence -+ l0-25%oof population(//60% of vulvo-vaginitis )
Predisposing factors (alkaline medium)
- Frequent sexual intercourse o
- Frequent use of alkaline vaginal douches
> Clrrutcal PrcruRE
- flrymptonntic(50%,")
- folitdvufito<taginitis -+ no PPdd (. . .osis & not.. .itis) -+ no p-us-eells "
- '/aginnt discfiarge (profuse, thin, greyish, malodorous)
(Fishy odoro is due to formation of amines from a.a. by anaerobic
bacteria especially apparent after intercourse or menstruation)
> luvrsttcATroN E
(O of the O AMSEL criteria are enough)
7l Characteristic vaginal discharge
2l Vaginal pH > 4.5
3l Clue cell (grmular appearance of vaginal epithelial cells due to
adherence of bacteria to their surface). Demonstrated by:
- Gram stain -+ gram -ve cocobacilli (H. vaginalis)
- Wet smear -+ drop of saline + drop of vag. discharge
4l tthiff test (add 10% KOH -+ fishy odor)
> CoNpLtcaloNS:
*
Pdf tor infection in :-
- Non-pregnant -+ chronic PID, UTI
- Pregnant + chorioamnionitis, PROM, PTL
- Wound infection after surgery e.g. vag. cuff after hysterectomy
*
However, there is no generalaercement on prophvlaxis
WhiteKnightLove
I
ql/n€rnhq? ,4
WhiteKnightLove
*-rH/n''1 '
lnfection 105
o PH -+ acidic a alkaline
Investigotion o Smear -+ Gram *ve o G -ve
o Fresh drop of disclnrge -> o motile flagellated organism
mycelia
hyphae or (slightly larger than leucocyte)
- Recurrence . Treat pdf (e.g. DM) I TReRt HusseNo (in atl inf) //
. Extend ttt for 3-6 weeks I Avoid vaginal douches
WhiteKnightLove
I
q//..rrnlng? rl
strains ol HPV.
o Long-lasting resolutlon ol visibh warts roquires a 0o0d
at any time,
o Sewnltypes of HPV particularly 16 and 18, are
WhiteKnightLove
lnfection 106
I
I
* usually type II
| "Papova virus family (genital warts)
' \sometimes 20Yotypel" \ the commonest /viral STD o
- DNA virus o - DNA virus "
- Incubation period -+ 5-7 days - 70 sero-types
-May affect -+ vulva, perineum, (6.11...:.16,18.....g1,gg,gs,89 I
WhiteKnightLove
Erfr€rih?q /4
Sterile
l
Doderlein's bacilli
Secretion abundant
Doderlein's bacilli
Secretion abundant
(a)
(b)
WhiteKnightLove
,o PrlmqrJ (l ry)
nical
.Symptoms -+ - Pain (soreness) & Pruritis vulvae
- Dysuria & Dyspareunia
- Discharge .....mention the discharge of O I O
.^Sigzs + red hot, swollerl edematous, tender
+ inguinal lyrnphadenitis * scratch ulcer
Ireatmen(
1l Of cause .... mention the ttt of O O I
2l- local
Good local hygiene d
. keep vulva dry & clean (best is neutral douche)
-- . Underwears should be cotton,loose, dry
- Antipruritic 4
antihistaminic t
anesthetic * cortisone
3l Geaeral measures to irrltatlon l
- Sedatives + Phenobarbitone
- Antihistaminics
WhiteKnightLove
lg ffirollnltls
Pqthologg: aeute inflammation of Barttrolin gland @.coli " )
W Synptoms -+ pain: 1$ aching then throbbing (if pus forms)
^Sigzs
+.
Red edematous skin + indr.ration
. Pus may be discharged from the duct
. Gland is palpable & tender
Fqts + complete resolution.....abscess formation .',
. ....chronic bartholinitis /
TTT - Bartholinitis + antibiotics + hot fomentation
- Bartholin abscess + incise & drainage
Cyst
of
e ffirolln a,st Bortholin's
glond
Pqthololq
- It is the commonest VULVAL " cyst /
- Due to obstruction of the gland duct by + infection, mucous, trdumd
TgDes
- Cysl of the ductis much more common / (lined by transitional epithelium)
- Cyst of the gland is rare (lined by columnar epithelium)
CIP o painless cystic swelling in the lower 7s ofthe labia majora
TTT
f. Marsuplallzation / "
- Elliptical incision of the cyst & suturing the edges to the surrormding
-
Advantages -+ preseryation of the lubricant function, less bleeding
2. Drcisloa (esp. posmenopausal d.r risk of hidden................)
WhiteKnightLove
os Prepubortol (dlldhood) Vuhovoglnltls h
PDF a thin vaginal mucosa (a.t. .l estrogen + J vaginal acidity)
Mode of infection
O erintrl
* concntra + cong. fistula, ectopic anus......parasites (oxyuris, amoebiasis)
* t,,f"r,*rry-+ transmission from adult ...srD (G, TV, monilia)
* tnaunroc + accidental FB in vagina { ......non-specific (staph, str,, E.coli)
* tteoptartc -+ sarcoma botryoids
0 Secontaty
* ct rta [rtb0on + diaper rash, soaps
* poo, hlgfl€ne + wiping perineum from anus to vagina
TTT
.GARAI il$P(lCll0iE +
antihistaminics, antipruritics, local hygiene
.nfAlltWf 0F I[
+ any discharge -+ smear, gram stain
(fllSE
antibiotic is given according to CaS
.ltl PEFfAl{f OSE + may give'E'?? locally to inorease resistance I
.lF PIPSISIWI/S$SAIIGIIOUS 9lS(l[APG[ + inspect for F.B. / tumors:
1P/R" X-oy, U/S, vaginoscope (or cystoscope)
TTT
lllslPoKloiF + antihistaminics, antipruritics, local hygiene
.mffl]rBlf $ If, (fllSE -+ any discharge -+ smear, gram stain
rding to CgS
(0'625mg) for few wks
. [l REFrA]{r
' lt ffilsloff senile endometritis
WhiteKnightLove
I 110 qlrea@h? r,
I ) flcute caN,
erutatiae uu.aniamls
. Non-specific -+ strept., staph., E.coli
. STD's -+ monilia-Tv,.........viruses. G-chlamydia
+Ainical oidua
Symptoms - General -+ FAHM-R
- Local -+ discharge, dyspareunia, SACK pAnl
Signs
. Red, swollen, tender on mobility,
. exuding mucopurulent orpurulent discharge
9) Chronlc cerulcltl
ku,satiae uuraniama
. Non-specihc. . . . . . STD' s. . ..chronic granulomatous (TB, B, actinomycosis)
. Either a
* Persistence of acute cervicitis + chronic (due to:)
- Glands are racemose -+ difficult drainage
- No monthly shedding of epithelium
- The glands are in the depth so if surrounded by fibrosis -+
difficult penetration of antibiotics
* Chronic from the start as -+ postoperative, postabortive,
postpartum infected lacerations
?affrotssical lstna
t. Chronic endocervicitis # normal cx exuding mucopurulent discharge
2. Mucous polvp ohyperplasia of endocx epith.-+ multiple small reddish polyps
g. Nabothian follicles //+ obstruction of gland ducts -+ multiple small retention
cysts either: bluish (full of mucus) or yellowish
$ns)
a. chronic hvpertrophic cervicitis # swelling & hyperemia of cx
s. Chronic atrophic cervicitis + cervical stenosis
6. Cervical ulcers Obrightred erosions (true ulcers)
z. Ectropion er eversion of the endocervical mucosa (d.t. bilateral
cx tears)
WhiteKnightLove
Qlinical pidua fit affecb many women.....mostly is asymptomatic)
* Symptoms.....congestive rymptoms
a Discharge -+ mucopurulent or purulent
d Pain +- Dysmenorrhea (congestive)
- Dyspareunia
- Deep lower abdominal pain (affection ofparametrium)
- Dorsal pain (affection of uterosacral ligaments)
? Bleeding +
eontact bleeding
lrueotiaaliaru
C.ulture +
swab from endocervix for gonorrhea or chlamydia
ps& TLC, CRP
B.rood - f
C.omplications
-Cofposcryy -+ to exclude malignant conditions
l. Prophylaxis
- Avoid sexualpromiscuity
- Aseptic techniques (delivery, DsC,IUCD)
- Prompt diagnosis & early ttt......otherwise....chronic cervicitis
2.l,ledical
- Warm vaginal douches
- Antiseptic pessaries e.g. albothyl /
- Antibiotics + not effective (deep seated infection)
4. Surgery
- Conization
- Amputation
- Rarely hysterectomy (extensive infection or if coexisting disease)
WhiteKnightLove
CERVICITIS
An infection of the cervicqt ECTROPION
ep.ithelium ond stromo, usuoily An erosion or infection in o
following erosion. goping or locerofed cervix.
Exposed
endocervix
Old heoled
teor t-
Cervicol polyp
with cervicllis
Cervix
\.
WhiteKnightLove
Dillumtial diaaruoio
l,@antsa of cenilcitis
?,Gausa of leucorrhea &, vaginal dixharge
),Qauses of contact bleeding
Definition+ bleeding after intercourse, vaginal examination, douching
Etioloov e . Cewicitis / cervical erosions I cewical ulcers
* f,aser tfrcrary e rapid healing with minimal fibrosis, less side effects
WhiteKnightLove
113 Qflzrnln rl
"
.f" Aadonotiltls M 4'
Tvrrs
ifrc o rare due to cyclic
frc o bilharziasis, T
F
Definition -+ pus in the uterus l. Endomyometritis occurs most commonly after a
Clinical picture
- Sympt. -+ FAIIMR * lower abdominal pain + sympt of p.congestion
- Signs -+ tender swelling pushing the uterus to the opposite side
Treatment -+ as pelvic abscess
WhiteKnightLove
lnfection 114
I
*' }" Po0vla lel0aneatoty dlsaasa 't'
DerrHrrrou
Infection & inflammation of upper genital tract i.e.
Tubes, ovaries, pelvic peritoneum (|uterus) O2-3Yo of population
ErrolocY
PDF
-Sexually active females with multiple sexual partners....usually after
menses (loss of cx plug, degenerated endomet, retrograde menstruation)
- IUCD users (Barriers * COC -+ * PIO;
- Recent instrumentation of uterus (e.g.D&C IHSG)
Routes of infection
I Ascending through
. LuurN (as chlamydial & gonococcal) e en[osatpingitis
. Lvllprnrtcs (esp puerperal & postabortive) o interstiti"afsatpingitis
) Direct from neighboring organs as appendicitis a perisafpingitis
> Blood spread as T.B.
f,cute PID
€fioW
- STD's esp coNococcus (40%), cHLAMypIA (60%
- Puerperal or postabortive
- Non-specific organisms (aerobic or anaerobic) :usually mixed
0atfrnhart
+
WhiteKnightLove
q4/r*rrla% r1
WhiteKnightLove
lnfection 115
Ainical oicttu.e
t. Symptoms (history of pdf +)
- General-+ FAHM-R
- Abdominal + acute lower abdominal pain
- Pelvic -+ congestive symptoms (pain, bleeding, discharge) o-
z. Signs
- - General -+ signs of infection
- Abdominal -+ . tendemess & rigidity in lower abdomen (peritonitis)
. maximum 3 cm above mid-inguinal point (tubal point)
- P/Y -+ tender movement of cx, tender adenexae * tender mass
eamnlicalfuna
+
o Recurrence.........Chronicity -esp chlamydir (chronic pelvic pain)
o Infeftility.............Ectopic pregnancy
tr Spread +........- Pelvic abscess formation
- - Thrombophlebitis
- Peritonitis, Septicemia
WhiteKnightLove
?rt errh?q r4
Cefoxitin I I Cefotetan
2gtYt6hr lo"lzetY/t2h Levofloxacin 500 mg
+ doxycycline 100 mg IV I l2hrs 1xlxl4
Clindamycin | | Gentamycin
900mg lol Loading Ceftriaxone I I Cefoxitin
IV/8hr lll 2mstr<g 250 mg I ORI 2 sm
0. | | _+r.s mg/ once I I once
NB.....antibiotics in pregnancy
- The most safe ate penicillins / cephalosporiru
- Anti-tubercnlorzs drugs could be given
- Quinolones are absolutely contraindicated
- Intravaginal antifungals (candida) are safe from first trimester
- Metronidazole (Trichomonas) can be used in 2"d &,3d timester
WhiteKnightLove
lnfection 1rG
I
9uufmenf
F( Prophylaxis
- Avoid sexual promiscuity
- Aseptic techniques (delivery, D&C,IUCD)
- Prompt diagnosis &early ttt......otherwise....chronic pID within ......
}( S,ctive
G General lines
- Antipyretics
- Analgesics & hot fomentation
- Antibiotics in cornbination in high doses
- Complete bed rest in Fowler position
- Treatment of partners
G lndications for hospitalization
- Nulliparity or low pariry -+ to avoid infertility
- Bad
T.:ffi ,ffi i*'":rm,:rfffltT:f"i# lTlr
G Antibiotic therapy rcontinued 48 hrs after resolution of feven
o Regimen L.......cefoxitin (2od) or cefotaxime (3'u) + Doxycycline
o Regimen II... .. .clindamycin * gentamycin
o Regimen III.....ampicillin * gentamycin * metronidazole
G Surgical intervention
- If Orcuere dhease refractorjt to medical ttt or
@ruptured /bwge tubooaarian abscess or
@ ge nera liqe d p eritonitis
\ I-a.?arotom:t // + drainage *
peritoneal toilet
+ ....... unilateral adenexectomy (to preserve fertility)
:
OR ..... .pelvic clearance TAH +BSO (for older age)
- If wall tuboouarian abscess -+ aspiration I (U/S guided or Laparoscopy)
- Pebic -+ drain by posterior colpotomy
abscess
- Thmrubopbkbitis -+ heparin
WhiteKnightLove
Blocked qnd distended
tubes in PID
WhiteKnightLove
&ialoart
. STD's. .... .non-specific. . ..chronic granulomatous (fB, B)
. Either a
- * Pemistence of acute PID (due to:)
2) hrosalpinx
- Suppurative salpingitis -+ thickened tube full of pus
- HSG + smaller in size than hydrosalpinx
- Less liable fortorsion than hydrosalpiro (infection -+ adhesions)
*Tuboousrlqn qbscesc 4 pyosalpinx communicating with ovarian abscess
3) Perisalpinsitis
- Thi kinked tube sr.urounded by adhesions + infertility, ectopic
5) Fitz-Hugt-Curtis wndrome
- Perihepatitis associated with chronic PID (esp chlarnydia, gonorrhea)
- CIP -+ recurrent upper right abdominal pain @D: cholecystitis)
- Inv. -+ laparoscopy + violin string-like bands of adhesions
efinical oidurc.
> Historv + previous attacks of acute PID or ectopic
) Svmntoms
o Infertility
---o Congestive symptoms +-
o Recurrent acute exacerbations
-
WhiteKnightLove
m@,d D,64hSili - ile opDc@re ot +.ro&n
Obstructed
fallopian tube
N^
\\
Tubo-ovarian
abscess
WhiteKnightLove
> S€..
o General -+ ill health....TB toxemia
a AMominal -+ signs of TB peritonitis or bilharziasis HSM
o Pelvic + . Tendenness (lower abdominal, cervical motion) r/
. Tubo-ovarian (adenexal) mass y'y'
. Fixed RVF
Oi,llswtial clAagnoai,o ..EruoouerRtosts, Ceucen OvRny, TB
lruaotioatioaa
- Diagnosis o
c.ullure -+ swab from endocx, rectum, pharynx (chlamydia, gonorrhea)
B.tood + t gSR, TLC, CRp
C.omplicotions
.ultrasound.......ifpain prevents PV & to follow up To abscess size
-
.Laparoscopy....if diagnosis is uncertain or no improvement within 4$-72hr
- Etiobg + TB (tuberculin, chest X-ray)
- Comp. O e.g. infertility + HSG, laparoscopy (+tuUa biopsy)
9wafment
Prophylactic -+ prevent puerperal, postabortive & surgical infection
Active
a Acute *K#:l:{i;fr1"#:1t3; 48 hours initia'v
. Antibiotics, hot fomentation
o If good re,sponse (improvement of general health) -+ continue
o If no response or there is a mass (abscess) from the start ) surgery
. Unilateral adnexectomy (if young + conservative)
. TAH + BSO (esp if bilateral & > 40 years)
.If infertility -+ tuboplasty fails .'. remove + IVF/ICSI (better)
a In chronic specffic -+ treat cause as B or TB
- WhiteKnightLove
Elrizrnln% rl
WhiteKnightLove
lnfection
I
119
I zo + muco+utaneous stage (6 wk - 6 m)
- General symptoms (blood spread), generalized LN
- Rash, mucous patches esp on palms & soles
- Condyloma latum (warly growth on vulva & perineum)
- Infectious
$ Sr a Gumma formation
- Early latent (within 4years of 2ry)
- Late latent (> 4 yrs): Neurosyphilis or cardiovascular syphilis
> lnvestiootlons
* Dark ground iltumination in l,v and 2,r + spirochetes "
* Non specific tests -+ Wassermann, Khan, RPR, VDRL
. Positive after 2 weeks from chancre
. May be false *ve in some immune diseases such as SLE
. Confirm by:
* Specific tests + TPl, FTA
> Treotmont
Early (lv, 2o,3o < lyear)
Benzathine penicillin 2.4 million units IM once
Or Procaine penicillin I million units / day for 10 days
Or Tetracycline / Erythromycin / Doxycycline (100 mg lx2xl4)
late syphilis
Benzathine penicillin 2.4 million units IM lweek for 3 wks
Neurosyphilis
Aqueous Penicillin G 12-24 million Ulday IV for 10 days
Then Benzathine penicillin 2.4 million units IM /week for 3 wks
WhiteKnightLove
> €tlologv
. Mycobacterium tuberculosis (human bacillus) > Mycobacterium boviso
. Becoming more cofllmon nowadays + 5% infErtility cases o S
> Boute of lnfactlon
- Blood borne /
(from lvpulmonary TB) -+ most common o
- Peritoneal spread (TB peritonitis)
- Lymphatic spread (TB of mesenteric LNs)
- Ascending with infected semen (TB epididymitis)
> Fohologv
S tubes " 1LOO9%,4 d adhesive or exudative
r PERISALeINGmS + miliary tubercles * adhesions
. Irutensrmlt SALPINGmS + thiclq nodules, caseation
. EttoosltpINGITIS + pyosalpinx full of caseous material
. SALPINGITIS ISTHMIcA NoDoSA
WhiteKnightLove
I sigras General / chest
Abdominal
Local +. Tubercles (nodules) in vulva, vagina, cervix
. Uterus + t fixed R\lF
. Adenexae + * adnexal swelling
. Douglas pouch + * nodules
) lnvostlootlons
General Blood (lLC, ESR), chest X-ray
+
O Endometrium @6C biopsy or menstrual shedding by cx cap) for
- ZeilNeilson stain -+ bacilli * excess lymphocytes
- Culfure on Dorset egg or Lowenstein Jensen medium
- Animal inoculation + guineapig (liver & spleen examined after 40 days)
O Vulva. vaeina. cervix + biopsy from lesions
O Tubes
* llSG + . Sausage shaped, lead pipe, hydrosalpinx, calcificatisn * patent
. Peritubal adhesions (localized collections of dye)
. Intrauterine adhesions, micropouche intravasations
Surglcd e
o No tubal microsurgery (v. imp)
o TAH & BSO are only done if large masses are present + fistula
WhiteKnightLove
> €tlologv + Schistosoma haematobium > Sch. Mansoni
> lnvestlootlons
- Urine & stool analysis + for ova
- Cystoscopy, sigmoidoscopy, laparosoopio biopsy
- Vulval &vagjrulbiopsy
- CFT
> TreoUnent
- Prophylactic
- Antibilharzial +. Biltricide @raziquantel) single dose (20-60 mglkg)
. Ambilhar (niridazol) 500mg 1x3x7
- Surgical excision ofresidual lesions
WhiteKnightLove
Other organisms
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lnfection 125
I
CDC REC FOR PID
Parerrteral
Cefoxitin I I Cefotetan
2 glY I 6hr l"' l2 gIY I l2h Levofloxacin Sffi mg
+ doxycycline 100 mg IV ll2hrs 1xkl4
Clindamycin Gentamycin
900 mg Loading Ceftriaxone Cefoxitin
IV/E hr 2 mgfi<g 250 mg 2gm
+ 1.5 mg/ once once