Gynecology pdf - LOKA

Gynecology

For

stage

http://goo.gl/rjRf4F

LOKA

http://www.muhadharaty.com/gynecology

Content

Topics:

Page:

 Gynecological history

 Gynecological examination

 Instruments

 Anatomy of female genital tract

 Normal and abnormal sexual development

 Hirsutism

 Disorders of the menstrual cycle

 Genital infections

 Fertility control and contraception

 Infertility

 Fibroid

 Endometriosis

 Ovarian cyst

 Polycystic Ovarian Syndrome (PCOS)

 Ovarian neoplasia

 Endometrial carcinoma

 Premalignant condition of the cervix

 Cervical cancer

 Conditions affecting the vagina and vulva

 Urinary incontinence

 Prolapse

 Abnormal vaginal discharge

 Gestational trophoblastic disease

Part1

: Gynecological History

Gynecological history taking has a number of questions that are not part of the standard
history taking format and therefore it’s important to understand what information you are
expected to gain when taking a gynecological history.

1- General information:

  Name.
  Age.
  Occupation.
  Residence.
  Blood group.
  Educational background.
  Husband information.

2- Date of admission + date of examination.

3- Chief compliant:

 A brief statement of the general nature and

duration of the main complaints.

 Try to use the patient’s own words rather than

medical terms at this stage.

 Even if the patient is being seen for an annual gynecologic examination, it is helpful

to begin the interview by asking whether the patient is experiencing any problems.

4- History of presenting illness:

This will differ slightly depending on the presenting complaint but follows a vague structure:

  If pain is involved ascertain site, radiation (if any) and character
  Onset
  Periodicity
  Duration
  Recurrence?
  Aggravating & relieving factors
  Severity

Additional information:

o  The circumstances at the time the problem began (activities, medical problems, medications).
o  The time course of the problem (transient problem, chronic, recurrent, persistent)
o  Relation between symptoms and the menstrual cycle.
o  New or old symptom.

Full Gynecological history:
1

General information

Date of admission +

date of examination

Chief compliant

History of presenting illness

Menstrual history

Past Gynecological History

Previous obstetric history

Sexual and contraceptive history

Systemic review

Past Medical History

Drug History

Family History

Personal History

Social history

o If the problem involves disruption of an otherwise normal function (such as amenorrhea), did the

patient have normal function at some point in the past?

o Characteristics of the problem, and associated symptoms.
o In the case of pain, this would include questions about the location, severity, nature (e.g., sharp,

dull, cramp-like), exacerbating factors, relieving factors, and whether the pain radiates to another
location.

o With respect to bleeding, this would include the frequency, amount, and duration of flow, and

whether the patient is experiencing fatigue or lightheadedness.

o To what extent is the problem interfering with the patient’s usual activities?
o Has the patient undergone any previous evaluation or treatment for the problem? If so, it is helpful

to obtain the patient’s permission to request these medical records.

o Why did the patient seek evaluation of the problem at this point? Have the symptoms changed or

increased in severity?

o Pelvic pain:

– Site, nature, severity.
– Aggravates or relieves the pain – specifically enquire about relationship to menstrual cycle and

intercourse.

– Does the pain radiate anywhere or is it associated with bowel or bladder function (menstrual

pain often radiates through to the sacral area of the back and down the thighs)?

o Vaginal discharge:

–  Amount, color, odor, presence of blood.
–  Relationship to the menstrual cycle.
–  Any history of sexually transmitted diseases (STDs) or recent tests.
–  Any vaginal dryness (post-menopausal).

5- Menstrual history:

 Age of menarche.
 Usual duration of each period and length of cycle  usually written as mean number

of days of bleeding over usual length of full cycle, e.g. 5/28.

  LMP  First day of the last period.
  Frequency and Regularity
  Amount of blood loss  more or less than usual, number of sanitary towels or

tampons used.

  Passage of clots or flooding.
  Any inter-menstrual or post-coital bleeding.
  Any pain relating to the period  use the SOCRATES method.
  Any medication taken during the period  including over-the counter preparations.
  If post-menopausal:

o  Date of last period.
o  Any post-menopausal bleeding.
o  Any menopausal symptoms (hot flushes, vaginal dryness, irregular periods).

6- Past Gynecological History:

 Previous gynecological symptoms, diagnosis, treatment (medical, surgical).
 Previous cervical smears  date of last, abnormal results, treatments (LETZ).

 Current contraception  COCP, POP, Depot, Implant, Coil.

7- Previous obstetric history:

  G: gravida  number of all pregnancies (delivered or aborted).
  P: para or parity  number of deliveries after 24 weeks (live or dead).
  A: abortion  number of expulsions of products of conception before 24 weeks

(normal or ectopic or hydatidiform)

 Each Pregnancy  Current age of child, Birth weight, Complications of pregnancy

and labor and after birth (puerperium).

 Ask sensitively regarding miscarriages / terminations / ectopic pregnancies 

Number, cause, complication of each.

8- Sexual and contraceptive history:

 The type of contraception used and any problems with it.
 Establish whether the patient is sexually active and whether there are any difficulties

or pain during intercourse.

9- Systemic review:

 Cardiovascular  Chest pain, Palpitations, Cyanosis, SOB, Syncope, Orthopnea, Ankle

swelling.

 Respiratory  Cough, Sputum, Chest Pain, SOB, Wheezing, Stridor, Hemoptysis.
 GI  Appetite, Nausea, Vomiting, Indigestion, Dysphagia, Weight loss, Pain, Bowel

habit.

 Urinary  Frequency, Dysuria, Polyuria, Urgency, Hesitancy, Nocturia, Incontinence.
 Nervous System  Vision, Headache, Weakness, Sensory disturbance, LOC, Seizures,

Incontinence.

 Musculoskeletal  Bone & Joint pain, Muscle pain, Joint swelling, Difficulty

mobilizing.

 Dermatology  Rashes, Skin breaks, Ulcers.

10- Past Medical History:

  Medical conditions  CIN, Genital Tract Cancers, Breast Cancers, etc.
  Previous surgery  abdominal or gynecological.
  Any hospital admissions  when & why?

11- Drug History:

 Regular medication  example: tranexamic acid (Treating heavy menstrual

bleeding), hormone replacement therapy (HRT).

  Over the counter drugs.
  Non-prescribed medications/herbal remedies.
  Contraception  COCP / POP / Coil / Implant / Depot.

 Allergens.

12- Family History:

 Consanguinity.
 Any illnesses that run in the family  Medical conditions or Gynecological

conditions.

 Uterine / Ovarian / Genital tract / Breast cancers.

13- Personal History:

 Smoking  How many cigarettes per day? for how many years?
 Alcohol  How many units a week? – Be specific about type / volume / strength of

alcohol.

 Recreational drug use.
 Sleep, Appetite, Micturition, Defecation, Weight loss or gain.

14- Social history:

  House? – the presence of stairs is important – will the patient manage?
  Who lives with the patient? – are they a source of support?
  Any carer input? – what level of care do they receive?
  Occupation?

Part2

: Gynecological Examination

Introduction:

 Obtain patient’s consent and with appropriate

privacy and sensitivity.

 The gynecologic examination includes

examination of the breasts, abdomen, and
pelvic organs.

 Many gynecologic problems have symptoms

that involve other organ systems.

General examination:

 Walking  poor mobility may affect decisions

regarding surgery or future management.

 Examining the hands and mucous membranes

for evidence of anemia.

 The supraclavicular area should be palpated for

the presence of nodes (Virchow’s node this is
also known as Troissier’s sign).

 The thyroid gland should be palpated.
 The chest and breasts should always be

examined (if there is a suspected ovarian mass,
as there may be a breast tumor with
secondaries of the ovaries known as
Krukenburg tumors).

 Pleural effusion may be elicited as a consequence of abdominal ascites.
 A general neurological assessment should be performed (suspicion of underlying

neurological problems).

 The next step should be to proceed to abdominal and pelvic examination.

Abdominal examination

General notes:

  The patient should empty her bladder before the abdominal examination.
  The patient should be comfortable and lying semi-recumbent.
  The patient is covered with a sheet from the waist down, but the area from the

xiphisternum to the symphysis pubis should be left exposed.

 It is usual to examine the women from her right hand side.

Inspection:

 Shape and size of the abdomen.
 Abdominal distention  gradual distention is caused by benign conditions like

fibroid or ovarian cyst.

  Abdominal mass.
  The presence of surgical scars (laparoscopy scars, Pfannenstiel scars).
  Dilated veins or striae gravidarum (stretch marks) should be noted.
  Hernia (the patient should be asked to raise her head or cough and any hernias or

divarication of the rectus muscles will be evident).

 Pubic hair distribution (absent or reduced in conditions that cause adrenal

insufficiency such as hypopituitarism, Turner's syndrome, Alopecia and Delayed
Puberty).

Palpation:

 First, if the patient has any abdominal pain she should be asked to point to the site –

the area should not be examined until the end of palpation.

 Palpation using the right hand and start at left lower quadrant and proceeding to the

other quadrants.

  Palpation should include examination for masses, the liver, spleen and kidneys.
  Mass (abdominal mass can palpate below it, pelvic mass cannot palpate below it).
  Examine the inguinal hernias and lymph nodes.
  Look for signs of peritonism (guarding and rebound tenderness).
  It may be helpful to ask the patient to raise her head so as to flex the rectus

abdominus muscles. Tenderness localized to the abdominal wall will typically worsen
with this maneuver.

Percussion:

 Ascites (shifting dullness, fluid thrill).
 An enlarged bladder due to urinary retention will also be dull to percussion (many

pelvic masses have disappeared after catheterization).

 Percussion is utilized to determine the size of abdominal and pelvic structures such as

the liver and masses.

 Percussion is also useful for assessing abdominal and pelvic tenderness.

Auscultation:

  This method is not specifically useful for the gynecological examination.
  Auscultation aids in the assessment of intestinal peristalsis (bowel sounds).
  Detection of abdominal bruits.
  Helpful in acute abdomen with bowel obstruction or a postoperative patient with

ileus.

Pelvic examination

General notes:

 Before proceeding to a vaginal examination, the patient’s verbal consent should be

obtained and a female chaperone should be present for any intimate examination.

 Patient asked to empty her bladder before the examination (except in urinary

incontinence).

 Midstream sample should be collected (If a urine infection is suspected).
 The examiner should wear gloves for this part of the procedure.

Inspection

  The patient in the dorsal position, the hips flexed and abducted and knees flexed.
  The left lateral position can also be used.
  Examine the external genitalia and surrounding skin, including the peri-anal area.
  Patient is asked to strain down to enable detection of any prolapse.
  Patient is asked to cough, as this may show the sign of stress incontinence.
  Any lesions or developmental abnormalities are noted.
  Hormonal abnormalities may cause changes in the external genitalia, such as

clitoromegaly. States accompanied by low levels of estrogen are associated with
atrophy of the mucosa.

 The skin should be inspected and palpated for superficial and subcutaneous lesions.
 The Bartholin’s gland openings may be visible, but the normal Bartholin’s gland is not

palpable.

 The urethra is inspected for the presence of caruncle and other findings.

Speculum:

 A speculum is an instrument which is inserted into the vagina to obtain a clearer view

of part of the vagina or pelvic organs.

 There are two principal types:

1- Bi-valve or Cusco’s speculum  allows visualization of the cervix, take sample
from the cervix, e.g. smear or swab.
2- Sim’s speculum  useful for examination of prolapse as it allows inspection of the
vaginal walls.

 There is plastic disposable speculums, but a metal one can be warmed to make the

examination more comfortable for the patient.

 Excessive lubrication should be avoided and if a smear is being taken, lubrication with

anything other than water should be avoided.

 The vagina and cervix are inspected for lesions. The vagina is also inspected for the

presence or absence of rugae to assess the level of estrogen present.

 The examiner assesses any vaginal discharge that is present for normalcy in

appearance, color, consistency, and odor. Physiologic vaginal discharge is scant in

amount, flocculent, and white. The pH of the normal vagina is less than 4.2. Normal
cervical mucus is clear.

Bimanual examination:

 This is usually performed after the speculum examination and is performed to assess

the pelvic organs.

 It is customary to use the left hand to part the labia and expose the vestibule and

then insert one or two fingers of the right hand into the vagina. The fingers are
passed upwards and backwards to reach the cervix

 The cervix is palpated any irregularity, hardness or tenderness noted.
 The left hand is now placed on the abdomen below the umbilicus and pressed down

into the pelvis to palpate the fundus of the uterus.

 The fundus  size, shape, position, mobility, consistency and tenderness are noted.
 The normal uterus is pear shaped and about 9 cm in length. It is usually anterior

(antiverted) or posterior (retroverted) and freely mobile and non-tender.

 The tips of the fingers are then placed into each lateral fornix to palpate the

adenexae (tubes and ovaries) on each side.

 The fingers are pushed backwards and upwards, while at the same time pushing

down in the corresponding area with the fingers of the abdominal hand.

 It is unusual to be able to feel normal ovaries, except in very thin women.
 Ovaries  Any swelling or tenderness is noted, although remember that normal

ovaries can be very tender when directly palpated.

 The posterior fornix should also be palpated to identify the uterosacral ligaments

which may be tender or scarred in women with endometriosis.

Rectal examination:

A rectal examination can be used as an alternative to a vaginal examination in:

  Children and in adults who have never had sex.
  It will help pick up a pelvic mass.
  To differentiate between an enterocele and a rectocele or to palpate the uterosacral

ligaments more thoroughly.

 Occasionally, a rectovaginal examination (index finger in the vagina and middle finger

in the rectum) may be useful to identify a lesion in the rectovaginal septum and when
one suspects endometriosis or a pelvic mass, or if there are symptoms attributable to
the rectal area.

Breast examination

  Systemic way (setting, inspection, palpation, examine L.N).
  Changes in pregnancy (enlargement, secondary areola).
  Nipple (retraction, cracking, discharge).
  Breast lump examination.

Part3

: Instruments

1: Bi-valve or Cusco’s speculum

  Consist of upper and lower plates.
  Enter through the vagina.
  Used to examine the vaginal wall, visualization of the

cervix, and take biopsy.

 At the beginning close the speculum and put it at 9

o'clock degree, then start to enter it through the
vestibule until reach the vagina, then rotate it to 6
o'clock or 12 o'clock, then open it and fixed it by
screw, complete the examination and investigations, then start to remove the speculum,
close the upper and lower plate by using the screw, rotate to 9 o'clock then remove it
from the vagina.

 In Cusco's speculum  no need for assistance and it is self-retaining.
 When the speculum inside the vagina, see the following:

o  Cervix: color, ulcer, abnormal discharge, nodules, erosions.
o  Fornices: fullness.
o  Lateral vaginal wall: rogue.

 At same time of examination do some investigations like:

o Cotton for high vaginal swap  put the cotton on the posterior fornix (site of

discharge accumulation) then remove the cotton without touching the vaginal
wall, then put it in container and write the name of the patient and the time of
examination and send it to the lab  swap for culture and sensitivity.

o Pap smear  use the spatula.

 Advantages:

o  It is self-retaining speculum.
o  It is easy to use.
o  The vaginal walls can be retracted to a variable extent.
o  It gives a good exposure of the cervix.
o  Both anterior and posterior vaginal walls can be retracted with a single

instrument.

o It causes least discomfort to the patient.

 Disadvantages: the space available for carrying out any procedure is limited by the rim

of instrument.

 Uses:

o  When the biopsy is to be taken from the cervix.
o  For cauterization of cervical erosions.
o  For insertion of IUCD.

2: Sim’s speculum

 Need for assistance by another person or nurse.
 Used for diagnosis to see the anterior and posterior

vaginal wall.

 Same procedure of Cusco's speculum, but we should

press sim's speculum downward to see the anterior
vaginal wall or pull it upward to see the posterior
vaginal wall.

 Uses:

o See the Bulging of bladder (cystocele): due to

weakness of anterior vaginal wall, you can examine it by asking the patient to
come with full bladder or ask the patient to cough so the bulging become more
obvious, and see some fluid.

o  Bulging of the rectum (rectocele)
o  Cystorectocele.
o  Used for retracting the posterior vaginal wall during dilatation & curettage (D & C)

and during dilatation & evacuation (D & E).

o  For taking biopsy from genital tract.
o  For routine per speculum examination.
o  Outdoor cauterization of erosion.

#Note: causes of prolapse: congenital, weakness.

 Disadvantages:

o An assistant is required.
o An anterior vaginal retractor is required to get a good view.

3: Ferguson's speculum:

 It is a tubular speculum having no valves.
 Advantages: it is protect the vaginal wall during

examination.

 Uses:

o  Taking biopsy or smear from the cervix.
o  For cauterization of cervical erosions.
o  For schiller's test ( medical test in which iodine solution is applied to the cervix in

order to diagnose cervical cancer).

o To protect the vaginal walls during decapitation operation with Gigli's wire.

4: Spatula

 Used for Pap smear  do it annually to screening for

cancer.

 Could be woody or plastic.
 Use it with Cusco's speculum, enter it to the vagina and

take the smear.

 At the top of the spatula there is lingual part (put it in

the inner part of the cervix) and shoulder part (put it in
the ectocervix).

 Rotate the spatula and take columnar cells (by lingual

part) and squamous cells (by shoulder part).

 Put the spatula on the slide and do fixation.
 Send the slide to the lab for cytology.

5: Sponge (swab) holding forceps:

 It has ring shapes tips, which may be serrated or

smooth.

 Uses:

o It used for holding the sponges to swab out

cavities (vagina for example).

o Some times when the anterior lip of the cervix is friable and cannot be held by

volsellum, sponge holding forceps can be used.

o  It can be used in place of ovum forceps.
o  For applying antiseptics over vulva, vagina or abdominal skin before operation.
o  It may be applied on infundibulopelvic ligaments to control bleeding in

myomectomy.

6: Uterine curette

  Used for dilatation and curettage (D & C).
  It is used under general anesthesia.
  Hormonal disturbances lead to increase thickness to 7

cm and this could be pathological or cancer  so do D
& C  first use uterine sound 4 then 5,6,7,8 to open
the os and it is used for dilatation to prevent injury 
then use curette  start form anterior then posterior
then lateral vaginal wall  bleeding and tissue  put
them in container  lab  histopathology.

 Could lead to uterine artery injury (severe bleeding).
 Types  Sim's curette, Sharp & blunt curette, Goldstein curette (nowadays it is not used

due to the risk of fluid embolism).

 Uses:

o To curette out the products of conception in cases of missed or incomplete

conception.

o To curette out endometrium in cases of endometrial diseases for diagnostic and

therapeutic purposes (in case of infertility, postmenopausal bleeding, endometrial
cancer).

o For checking curettage: done 1 week after evacuation of H.mole.

 Complications  Hemorrhage, sepsis, perforation of the uterus, vigorous curettage lead

to amenorrhea due to total removal of endometrium (Asherman's syndrome).

7: Cervical dilator:

 Types: Hegar's dilator, Hawkins Ambler's dilator.
 Uses:

o  Dilatation & curettage (D & C).
o  Dilatation & evacuation (D & E).
o  To diagnose incompetence os of cervix by passing

no. 8 Hegar's dilator in non-gravid uterus.

o In operation of cervix  amputation of cervix,

repair and cauterization of cervix.

o For insufflations tests Insufflate means to

deliver air or gas under pressure to a cavity of
chamber of the body.

o To relive some causes of spasmodic

dysmenorrhea.

 Complications  sepsis, hemorrhage, perforation of the

uterus, cervical tear which cause cervical incompetence
or cervical dystocia at a later date.

8: Anterior vaginal wall retractor:

 It has 2 loop-shaped ends with transverse serrations.
 Uses  it used with Sim's speculum to retract the anterior

vaginal wall for visualizing the cervix and anterior fornix.

Hegar's dilator

Hawkins Ambler's dilator

9: Simpson's uterine sound:

 It is a granulated metallic rod about 12 inches long.
 The distal end is curved at an angle of 60 degree and it

is 2 inches long (normal cervical length) and the tip of
the instrument is blunt.

 Uses:

o To ascertain the size and direction of the uterus

before passing the cervical dilator.

o To ascertain the position of abnormal uterine

content like tumor, polyp, etc.

o  For correction of the a mobile retroverted uterus (with precaution).
o  For insufflations tests.
o  The uterus is sounded routinely before operations on uterus or cervix.

 It is not used when  pregnancy is suspected, cervical infection is present.
 Complications  sepsis, perforation of the uterus.

10: Volsellum forceps:

 It is used to hold the anterior lip of the cervix when it is

not friable that is in gynecological conditions.

 It has got sharp teeth at the end which provide firm

grip.

 Uses:

o For holding the anterior or posterior lip of cervix in various operations  D & C,

cauterization of cervix.

o  To test the mobility of cervix and laxity of ligaments in prolapse.
o  To bring down fundus of uterus in vaginal hysterectomy.
o  For small fibroids in myomectomy.

11: Self-retained retractor:

 Used for retraction of abdominal wall.
 Not need surgeon assistance.

12: Killund forceps:

  Has only one curve.
  Cannot be locked.
  Used for the rotation of the baby.
  Need good experience physician.
  It is not used widely nowadays because of its severe

complications.

13: Long curved forceps:

 Has two curves, one for cephalic presentation, the

other for breech.

 Can be locked.
 Cannot be used for rotation.

Part4

: Important subjects

Subject1: Anatomy of female genital tract

#Development of the genital organs:

 Start by the 5

week.

 The origin of all genital organs form  Genital ridge,

mesonephric (wolffian) duct, para-mesonephric
(mullerian) duct.

 Development of external genitalia:

o  Genital tubercle  clitoris.
o  Genital folds  labia minora.
o  Genital swellings  labia majora.

#Anatomy:

 The vulva (external genitalia) include  mons pubis,

labia majora, labia minora, clitoris, vestibule and vestibular orifice, greater vestibular
glands.

 The vagina  posterior wall (9cm), anterior wall (7cm), fornices (anterior, posterior,

two lateral), contain rugose, has no glands, Doderlein's bacillus (PH 4.5).

 The uterus  corpus (fundus, cornu, isthmus), anatomical internal os, anteversion and

anteflexion, layers (peritoneum, myometrium, endometrium), ligaments (cardinal,
round, uterosacral).

 The cervix  2.5-3 cm, supra-vaginal part (columnar epithelium), vaginal part

(stratified squamous epithelium), transformation zone, anatomical external os.

 The fallopian tube  interstitial part, isthmus, ampulla, infundibulum.
 The ovaries  almond shape, solid, grayish pink, 3cm long, 1.5 cm wide, 1cm thick, 10

g weight, ligaments (ovarian, suspensory, mesovarian).

#Bartholin's gland:

 Two pea size glands, lie at the base of each bulb and open via a 2 cm

duct into the vestibule between the hymen and the labia minora.

  Sometimes the duct of this gland obstruct leading to Bartholin cyst.
  If infection develop it may lead to Bartholin abscess.
  Painless swelling (cyst), painful swelling (abscess).

Subject2: Normal and abnormal sexual development

#General information:

  Puberty occur in girls between 8-14 years.
  Puberty occur in boys between 9-14 years.
  Puberty occur under control of hypothalamo-pituitary-ovarian axis.
  Influencing factors  genetic factors, enviromental factors (nutritional status), leptin

(regulates appetite & metabolism through hypothalamus), psychological factors,
geographic location.

#Female Pubertal stages (Tanner):

 P1...prepubertal ( typically age 10 &younger )
 P2... early development of subareolar breast bud+/- small amount of pubic & axillary

hair.

 P3... increase in size of palpable breast tissue & areola, increased dark curled

pubic/axillary hair.

 P4... breast tissue & areola protrude above breast level. Adult pubic hair but no spread

to medial thights.

 P5... mature adult breast. Pubic hair extends to upper thigh.

#Male Pubertal stages (Tanner):

  P 1...prepubertal (testicular volume < 2 ml, small penis) typically age 9 & younger.
  P 2...enlargement of scrotum & penis, few long dark pubic hair.
  P 3...lengthening of penis. Further growth of testes & scrotum. Pubic hair darker,

coarser & more curled.

 P 4...penis increases in length & thickness. Increased pigmentation of scrotum. Adult

pubic hair but no spread to medial thighs.

 P 5...genitalia adult in size & shape. Pubic hair spread to medial aspect of thighs.

Prader orchidometer used to measure

the size of testis during puberty

#Precocious puberty:

 Refers to the development of secondary sexual characteristics <8yrs in girls & <9yrs in

boys.

 Causes  Gonadotrophin dependent (idiopathic,

congenital, irradiation, surgery, sever head
trauma, tumors) Gonadotrophin independent
(virilisation of female (CAH), feminisation of boy
(estrogen producing leydig tumor), adrenal tumor,
ovarian tumor, exogenous androgens, estrogen,
HCG-secreting tumor (teratoma)).

 Treatment  Psychological support, GnRH

agonists, treat systemic disease, surgery to
remove tumor.

#Delayed puberty:

 Puberty delay if  no breast development by age 13 in female, no menses by age of

15, testicular size <2.5 cm or 4 ml or pubic hair is not present by age of 14 in male.

 Causes  Hypogonadotrophic (idiopathic, renal failure, Crohns dis, malnutrition,

exercise, tumor of pituitary, hypothyroidism, hyperprolactinemia, PCOS, Kallman's
Syndrome), Hypergonadotrophic (Turner syndrome, Klinefelters syndrome, complete
androgen insensitivity, mixed gonadal dysgenesis, irradiation, chemotherapy, surgery,
testicular torsion, trauma, mumps orchitis, autoimmunity), Eugonadotrophic
(imperforate hymen, vaginal

 Treatment  Psychological support, Treat systemic disease, Promote puberty/ growth

if necessary, in male case (testosterone, hCG), in female case (estrogen replacement,
pulsatile administration of GnRH).

#Congenital Adrenal Hyperplasia (CAH):

 Autosomal recessive, most common form is 21-hydroxlase deficiency.
 Clinical presentation in new born female:

o  Enlargement of clitoris.
o  Excessive fusion of genital fold.
o  Thickining

& rugosity of labia majora.

o Internal genital organs are present.
o Dangerous salt losing syndrome.

 Affected male  presented at age 0f 1-4 weeks with failure to thrive, reccurent

vomiting, dehydration, hypotension, shock.

 Investigation  Karyotype, 17a hydroxyprogesterone, Electrolyte abnormality, Pelvic

US.

 Treatment of CAH  Medical control of underlying disorder (Cortisol, correction of

electrolyte disorder) Surgical correction of underlying anatomical abnormality
(Reduction of clitoris, Clitoroplasty, Division of the fused labia)

#Turner's syndrome:

 Karyotype 45XO, Phenotype female
 Clinical signs  edema of hand

& feet, Short stature, Absent

secondary sexual characteristics, Wide carrying angle of the arms,
Webbed neck, Broad chest with widly spaced nipples, Streak
ovaries, Normal internal genital organs.

 Diagnosis  Karyotype, Marked elevation of LH, FSH, Reduced

Estrogen, US (Cystic hygroma).

 Treatment  Induction of puberty by estrogen, Induction of

menstruation by progesterone, Growth hormone.

#Klinefelter syndrome:

  Karyotype 47XXY
  Phenotype..male
  Small azospermic testis, abnormal secondary sexual characteristics,

Gynecomastia, infertile or reduced fertility.

 Testosterone is low normal, raised FSH, LH, estrogen.
 Treatment  Androgen, Reduction mammoplasty.

Case of ambiguous genitalia  the

most common cause is CAH.

#Anomalies of internal genital organs (Mullerian Anomalies(:

 Types:

 Clinical manifestation  Asymptomatic, Dysmenorrhoea, Dyspareunia, Pelvic pain,

Infertility, Recurrent miscarriage, Malpresentation, Preterm labour, Rarely ectopic
pregnancy.

 Diagnostic evaluation  pelvic US, CT, MRI, sonohistogram, HSG, hysteroscopy,

laproscopy.

 Treatment  many require no treatment, uterine septa can be excised with

hysteroscopy.

#Imperforated hymen:

Question



16 years old female presented with primary amenorrhea, on examination the

doctor see this picture, what is your diagnosis?

 History  primary amenorrhea, intermittent cyclical abdominal pain (dysmenorrhea),

difficulty with micturition and defecation, retention of urine in some cases.

 Examination  Normal stature and have normal secondary sexual characteristic,

abdominal mass, vulval inspection (tense bluish bulging membrane), rectal examination
(mass at the vagina).

 Investigations  US, Laparoscopy, Laparotomy.
 Treatment  After explanation of the condition and obtaining parents consent, a

cruciate incision (+) in the hymen allows drainage of the retained menstrual blood, also
give antibiotics. From medico-legal point of view, the girl must be given a report
confirm that the hymen was opened by surgical operation as treatment.

Abdominal mass with imperforate hymen

Observation of the introitus will display a tense bulging bluish
membrane which is the hymen.

Vaginal agenesis.

Not to be confused with imperforate hymen.

Diagram of hematometra and hematocolpos with imperforate
distal transverse vaginal septum.

Vaginal septum

Subject3: Hirsutism

 Definition: it is excessive growth of terminal (coarse) hair on the face, chest, back, inner

thigh in women following a male like patter.

 Viriliaztion  hirsutism + signs of androgen excess (acne, frontotemporal baldind,

deepening of the voice, a decrease in breast size, clitoral hypertrophy, increased
muscle mass, amenorrhea/oligomenorrhea.

 Causes  adrenal disorder (congenital or adult onset adrenal hyperplasia, adrenal

producing tumors), ovarian disorders (

PCOS

, androgen producing tumor, chronic

anovulation), pituitary disorders (cushing's syndrome, acromegaly), drugs (phenytoin),
intrinsic factors (genetic, racial, familial, idiopathic), intersex problem (turner's
syndrome).

 Signs and symptoms  male pattern of hair distribution, features of PCOS, thyroid

disease, Cushing syndrome, signs of virilization, signs of insulin resistance,
galactorrhea, pelvic mass.

 Investigations  free testosterone, 17 hydroxyprogesterone, LH:FSH ratio >3, 5a RA,

pelvic US, CT, MRI, Dexamethasone suppression test.

 Treatment:

o General  reassurance, stop smoking, weight reduction.
o Specific  ovarian suppression (OCP), adrenal suppression (corticosteroids), anti-

androgens (spironolactone), 5aRA inhibitors (Finasteride), Insulin sensitizer
(Metformin).

o Local  suppress hair growth, remove hair pigment, temporary depilation,

temporary epilation, permanent removal.

o Surgery.

Ferriman-Gallway score:

 From 0 (no growth) to 4 (complete and heavy cover).
 9 locations )upper lip, chin, chest, upper back, lower back, upper abdomen, lower

abdomen, upper arm, thigh).

 In white races, a score of 8 and above is considered indicative of androgen excess.

Subject4: Disorders of the menstrual cycle

Subject5: Genital infections

Disease

How you get it

Symptoms

Treatment

Partners

Diseases that are transmitted sexually

Chlamydia

Infection of mucous

membranes lining

the genitals can lead

to inflammatory

disease (PID) in

women and infertility

in men and women.

By having vaginal

or anal sex without

a condom with

someone who has

the infection; from

mother-to-baby

(eye and chest

infection)

Women often

have no

symptoms or may

have pain with

sexual

intercourse, lower

abdominal pain,

changes in

bleeding pattern.

Men may have no

symptoms or may

have watery or

thick discharge

from penis, pain or

urinating.

Antibiotics.

Recent sexual

partners need

treatment. Don't

have sex until 7

days after starting

treatment and until

sexual contacts

have been treated.

Gonorrhoea

Bacterial infection of

genitals, throat or

anus, can lead to

infertility

particularly in

women.

By having vaginal,

anal or oral sex

without a condom

with someone who

has the infection;

from mother-to-

baby (eye

infections).

Women usually

have no

symptoms, but

may have pain

with sex, vaginal

discharge, lower

abdominal pain.

Men may have no

symptoms or

discharge from

penis, discharge

from anus, pain in

testicles, pain on

urinating.

Antibiotics.

Sexual partners

must be tested and

treated if positive.

Avoid sex until

seven days after

treatment is

completed.

Condoms provide

some protection,

but not total.

Syphilis

Bacterial infection

entering the body

through breaks in

skin or linings of the

By having vaginal,

anal or oral sex

without a condom

with someone who

has the infection;

Painless ulcer

(chancre) usually

on genitals; later

Antibiotics with follow-

up blood tests.

Sexual partners

must be tested and

treated if positive.

Current health

regulations advise

Disease

How you get it

Symptoms

Treatment

Partners

genital area; over

time, goes on to

damage internal

organs (heart, brain,

spinal cord)

from mother-to-

baby across

placenta during

pregnancy

(congenital

syphilis).

swollen glands,

rash, hair loss.

no sex until you are

cleared.

Genital warts

Human

papillomavirus (HPV)

causes fleshy or flat

lumps

– may be

present even if not

visible

HPV transmitted by

direct skin-to-skin

contact, usually

during sex; from

mother-to-baby.

Sometimes no

identifiable source

of transmission.

Fleshy or flat

lumps on or

around genitals,

anus, groin or

thigh.

Visible warts can be

treated, but the

infection cannot be

cured. Discuss

vaccination with your

general practice.

Condoms provide

some protection,

but not total.

Genital herpes

Herpes simplex virus

causes skin infection

usually on mouth

and lips (cold sores)

or on genitals.

Close skin contact

with someone with

the virus; from

mother-to-baby.

Painful, red

blisters, little sores

or ulcers, flu-like

symptoms, and

sometimes a

discharge.

Anti-herpes drugs and

pain relief can be given

to treat symptoms, but

the infection cannot be

cured. Some may need

medication to prevent

further outbreaks.

Partners may or

may not catch

herpes. Do not

have sex when

open sores are

present. Condoms

provide some, but

not complete,

protection.

Non-specific

urethritis (NSU)

Infections that cause

inflammation of the

urethra.

Can be caused by

chlamydia or by

bacteria, viruses or

other organisms.

Women usually

have no

symptoms. Men

have discharge

from the penis,

pain on urinating,

but sometimes

there are no

symptoms.

Antibiotics.

Partners need to be

examined and

treated.

Disease

How you get it

Symptoms

Treatment

Partners

Trichomoniasis

Trichomonas

vaginalis

, a small

parasitic organism,

causes irritation in

the vagina in women

and can cause an

irritation inside the

penis in men.

During sexual

intercourse with an

infected person.

Women may have

no symptoms, but

there may be a

yellowy-green

frothy vaginal

discharge. Men

usually have no

symptoms.

Antibiotic tablets and/or

vaginal pessaries.

Treat with

antibiotics to avoid

re-infection. Don't

have sex until 7

days after starting

treatment and until

sexual contacts

have been treated.

Diseases that can be transmitted sexually or may be transmitted in other ways

Hepatitis A

Viral infection which

affects the liver.

Mainly through

contaminated food

or water or not

hand-washing after

toilet/before food

etc. Can be through

anal sex and oral-

to-anal contact

(rimming).

Often no

symptoms, or may

have mild flu-like

illness, or

vomiting,

abdominal pain,

dark urine and

yellowing of the

skin and whites of

the eyes.

Immunisation for

prevention. Good

hygiene and hand-

washing. Avoid alcohol

and drugs. Eat a well-

balanced low-fat diet.

Immunisation for

prevention and

avoid anal sexual

practices until

recovered.

Hepatitis B

Viral infection which

affects the liver.

By having vaginal,

anal or oral sex

without a condom

with someone who

has the infection;

form mother-to-

baby. By sharing

needles, syringes,

toothbrushes,

razors and

unsterilized

instruments that

pierce the skin.

Blood transfusion in

countries that do

May have no

symptoms or mild

flu-like illness or

vomiting,

abdominal pain,

dark urine and

yellowing of the

skin and whites of

the eyes.

Rest, exercise and

avoid alcohol, drugs

and smoking. Eat a

well-balanced low-fat

diet. Check any

prescribed or over-the-

counter medicines are

safe to take.

Always use a

condom if partner is

not immunised.

Protection is

offered to babies

on the

immunisation

schedule and to

children under 16

years. Free

immunisation is

available for

household and

sexual contacts.

Disease

How you get it

Symptoms

Treatment

Partners

not pre-test blood

for transfusion.

Hepatitis C

Viral infection which

affects the liver.

After contact with

infected blood or by

sharing needles or

syringes or possibly

through sexual

contact. Blood

transfusion in

countries that doe

no pre-test blood

for transfusion.

Often no

symptoms or may

have mild, flu-like

illness or vomiting,

abdominal pain,

dark urine and

yellowing of the

skin and whites of

the eyes.

Rest, exercise and

avoid alcohol, drugs

and smoking. Eat a

well-balanced low-fat

diet.

Sexual and needle-

sharing partners

can have a blood

test to check for

Hep C antibodies.

HIV

Human

Immunodeficiency

Virus

attacks the

white blood cells and

causes damage to

the immune system

so that it can be

difficult to fight off

infections.

HIV is transmitted

through blood,

semen and vaginal

fluids, sharing

needles and from

mother-to-baby.

Blood transfusion in

countries that do

not pre-test blood

for transfusion.

Usually no

obvious symptoms

for many years.

No immunisation or

cure available although

some secondary

infections can be

treated or prevented.

Keeping well for longer

is possible with good

care. Women with

HIV/AIDS need a

cervical smear yearly.

Practice safer sex

to prevent

transmission.

Partners should

ask for an HIV test.

Pelvic inflammatory

disease (PID)

An infection of the

womb and fallopian

tubes that can cause

infertility.

Usually by having

vaginal sex without

a condom with

someone who has

gonorrhoea or

chlamydia.

Pain during sex,

sore abdomen or

back, heavy,

irregular or painful

periods, spotting,

high temperature,

feeling sick;

sometimes no

symptoms.

Antibiotics and rest.

Need to check for

STIs and be treated

to avoid

reinfection. No sex

until treatment is

completed and until

sexual contacts

have been treated.

Pubic lice

– crabs

Small lice that live in

the pubic hair and

By close body

contact, usually

during sex with an

Intense itching in

the pubic area,

Special shampoo,

cream or spray applied

Treat partners of

the last 3 months in

Disease

How you get it

Symptoms

Treatment

Partners

cause irritation.

infected person.

Can be spread via

infected bedding

and clothing.

small nits (eggs)

on pubic hair.

to pubic area. Wash all

clothing and bed linen.

the same way at

the same time.

Scabies

Small mites that

burrow into the skin

cause irritation.

By close body

contact, sometimes

during sex. Can be

spread by sharing

clothes or bedding.

Itching, worse at

night, and a rash

on the body.

Special lotion, cream or

ointment. Wash all

clothing and bed linen.

Treat partners of

the last 3 months in

the same way at

the same time.

Infections that are not sexually transmitted but can affect the genital area

Thrush or

candidiasis

Irritation of mucous

membranes from a

yeast organism. It

can occur in or

around the vagina,

and on the tip of the

penis.

Yeast overgrowth

may occur when

antibiotics are

used, during

pregnancy, with

diabetes, or when

immunity is

lowered. It can

occur after sex, but

also without sex.

Women have

vaginal or vulval

itching and a thick,

whitish vaginal

discharge. Men

have itching and

may have a red

rash on the head

of the penis or a

discharge under

the foreskin.

Creams and pessaries

for local treatment.

Anti-fungal tablets may

be given in severe

cases. Salt water baths

for men are usually

effective.

Need treatment if

showing symptoms.

Cystitis

Bacteria cause

inflammation of the

bladder lining; can

spread to kidneys

and cause damage

to kidney function.

Bacteria from

around the anus

getting into the

urethra and

bladder, not

emptying the

bladder properly.

Much more

common in women

than men.

Burning sensation

when urinating,

needing to urinate

urgently and more

often than usual,

cloudy,

bloodstained or

smelly urine,

aching in lower

abdomen or back.

Antibiotics after urine

test if symptoms last

longer than a day, drink

plenty of water, use

pain relief and using

alkalisers, e.g. Ural,

Citravesent

Disease

How you get it

Symptoms

Treatment

Partners

Bacterial vaginosis

If the control of the

normal bacteria in a

healthy vagina fails,

an overgrowth of

certain bacteria can

occur. The

acid/alkaline balance

is upset and irritation

results.

It may be brought

on by anything that

changes the

balance in the

vagina, eg, new

sexual partners,

increased sexual

activity.

Greyish white,

smelly vaginal

discharge.

Oral tablets and/or

vaginal pessaries.

Amsel's criteria

for diagnosis of bacterial vaginosis in which at least three out of four

should be present and these are:

• Thin, gray, homogenous discharge.

• Clue cell on microscope (vaginal epithelial cells so heavily coated with bacteria that the

border is obscured).

• PH of vagina> 4.5 (usually between 4.7-5.7).

• The addition of KOH to the vaginal secretions (the “whiff” test) releases a fishy, amine

like odor.

Subject6: Fertility control and contraception

#The ideal contraceptive method should:

  Highly effective
  No side effects
  Cheap
  Rapidly reversible
  Widespread availability
  Acceptable to all cultures and religions
  Easily distributed
  Can be administrated by non- health care personnel.

#Combined oral contraceptive pills (COCP):

 Once daily pill, easy to use, very high degree of protection

against pregnancy, with many other beneficial effects, it is
mainly used by young, healthy
Formulation  Synthetic Estrogen (Ethinyl estradiol) +
Synthetic progestogens (norethindrone, levonorgestrel,
gestodene).

 COCP contain 21 pills that contain the active ingredient, one pill to be taken daily,

followed by a 7 placebo pills.

 Method of use  The patient begins taking the pills on the first day of menstrual cycle

then in the next cycles they are administered in fifth day of the cycle and continue for
21 days, each day at the same time, then discontinued for 7 days to allow for
withdrawal bleeding that mimics the normal menstrual cycle which occur after 3-5 days
from stopping pills.

 Mode of action  centrally inhibition of ovulation, Peripheral effects (Making

endomtrium atrophic and hostile to an implanting embryo, altering cervical mucus to
prevent sperm ascending into the uterine cavity).

 Absolute Contraindication  Circulatory diseases (IHD, CVA, HT, arterial or venous

thrombosis), Acute or severe liver disease, Oestrogen-dependent neoplasms (breast
cancer), Breastfeeding <6 weeks post-partum, Smoking ≥15 cigarettes/day and age
≥35, Focal migraine.

 Relative contraindications  Generalized migraine, Long-term immobilization, •

Irregular vaglinal bleeding, Less severe risk factors for cardiovascular disease (obesity,
heavy smoking, diabetes).

 Side effects  Venous thromboembolism, Arterial disease (hypertention, myocardial

infarction and thrombotic stroke), Mortality, Carcinogenic effect (Breast cancer,
Cervical cancer, Liver cancer), CNS (Depression, Headaches, Loss of libido),
Gastrointestinal, Genitourinary system, Chloasma, Leg cramps.

 If pills are missed  Less than 12 hours late (Don't worry. Just take the delayed pill at

once, and further pills as usual), More than 12 hours late (Take the most recently
delayed pill now + Use extra precautions (condom, for instance) for the next 7 days).

 Positive health benefits  treat heavy or painful periods, improve premenstrual

syndrome(PMS), reduce the risk of pelvic inflammatory disease(PID), decreased
incidence of benign breast lump, decrease number of functional ovarian cyst, *less
endometriosis, against both ovarian and endometrial cancers, treatment for acne.

 Important questions during history taking  parity, family history, menstrual history,

any medical disease.

 Causes of failure rate (get pregnant) in COCP  missing pills, low dose of active

ingredient, irregular taking of pills or different time of administration, taking another
drug like ampicillin, gastroenteritis (defect in absorption).

#Combined oestrogen and progesterone vaginal ring:

  It is soft ring that a woman can insert into vagina.
  Women who use Ring leave the ring in place for 3 weeks during a month.
  During the 4th week, the ring is removed for 7 days.
  A new ring is used for each cycle.

#Combined hormonal patches:

  Contain Oestrogen and progestogen
  Patches are applied weekly for 3 weeks, after which there is a patch-free week.
  Contraceptive patches have the same risks and benefits as COC.
  They are relatively more expensive, may have better compliance.

#Progesterone only contraception:

 Methods  progestogen-only pill (mini-pill), subdermal

implant (Implanon), injectables, hormone-releasing
intrauterine system.

 Mechanism of action  central effects (inhibit ovulation)

peripheral effects (local effect on cervical mucus making it
hostile to ascending sperm, Local effect on the endometrium making it thin & atrophic
thereby preventing implantation, cause decreased tubal and endometrial motility).

 Side effects  Menstrual disturbances, Functional ovarian cyst, ectopic pregnancy.
 Indications of Progestogen-only pills  breastfeeding, older age, cardiovascular risk

factors, diabetes.

#Injectable progestogens (Depo-Provera):

 Given by deep intramuscular injection.
 Most women who use it develop very light or absent

menstruation.

 Depo-Provera will improve PMS and can be used to treat

menstrual problems such as painful or heavy periods.

 It is particularly useful for women who have difficulty

remembering to take a pill

 Single IM injection every 3 months.
 Side effects  weight gain, delay in return of fertility, persistent menstrual irregularity,

irregular vaginal bleeding or amenorrhea, risk of osteoporosis.

 Indications  contraindication to estrogen, Following rubella vaccination in

puerperium, -Husband waiting for effect of vasectomy, Mental retarded women,
Breast-feeding, population control in developing countries.

#Subdermal implants

 Implanon consists of a single silastic rod that is inserted

subdermally under local anaesthetic into the upper arm.

 It releases the progestogen etonogestrel 25-70 Mg daily.
 Norplant, which is withdrawn from the market It lasts for

3 years and thereafter can be easily removed or a further implant inserted.

 Implanon is particularly useful for women who have difficulty remembering to take a

pill and who want highly effective long-term contraception.

 There is a rapid return of fertility when it is removed.
 It works for 1 year.

#Copper Intrauterine device:

 Mechanism of action  Induce inflammatory reaction

within the endometrium, toxic to the sperm and oocyte and
the embryo, interfere with the fertilization, interfere with
sperm motility and oocyte capability of fertilization and
implantation.

 Complications  Bleeding and pain, Infection(PID), Perforation, Expulsion, Intrauterine

pregnancy, Ectopic pregnancy.

 Contraindications  Nulliparity and infertility, Active infection, Uterine anomalies

increase risk of expulsion and perforation, gynecologic malignancy, genital bleeding of
unknown cause, gestational trophoblastic disease.

#Levonorgestrel releasing IUD "merina":

 The LNG IUS is made of flexible plastic
 Mechanism of action  Thickens cervical mucus, Inhibits sperm

function in uterus, Reduces monthly growth of the lining of the
uterus, lessen menstrual blood loss in women who have heavy
menstrual flow.

 What are the most common side effects of the LNG IUS?

o 10+ in every 100 women are likely to experience the

following  Headache, Abdominal/ pelvic pain, Bleeding
changes, Vulvovaginitis, Genital discharge.

o 1 to 10 in every 100 women are likely to experience the

following  Depression, Migraine, Nausea, Acne,
Hirsutism, Back pain.

 Merina  available, expensive, white color, larger, not

metallic.

 Time of insertion of both types of IUD  day 3-5 of the cycle because there is no

pregnancy and the cervix is patulous during this period.

#Method of insertion of ICD:

 How to check that the device is in the uterus? Thread in place, by US.
 Causes of thread not in place  expulsion, perforation in myometrium, thread is coiled

in  so you can localize it by examination or US or abdominal X-ray.

 Complications at time of insertion  infection, pain, bleeding, trauma (perforation).
 Copper still for 5 years, Merina still for 10 years,

Copper IUD LNG IUD X ray with LNG IUD

#Mechanical contraception:

  Male condom  protective against STDs.
  Female diaphragm  application at cervix with spermicidal effect.
  Complications  allergy, rash, failure.

#Emergency contraception:

 Levonorgestral  0.75 mg, take 2 tablets.
 IUCD  within 5 days of sexual intercourse.

#Natural family planning:

 Avoid intercourse 5 days before and after ovulation.
 To know the time of ovulation:

1- Temperature increase in ovulation, so calculate the body temperature every

morning for 3 months.

2-  At time of ovulation there is localized abdominal pain and breast tenderness.
3-  Spotting  few drops of blood.
4-  Cervical mucosa  become thin and watery and colorless.
5-  US  size of mature follicles (18-20).

 Other type called withdrawal  no ejaculation in female genital tract.

#Permanent contraception:

 Bilateral tubal ligation:

o  Should ligate both uterine tubes.
o  Types  removal, clips, band, essure.
o  Essure  screw in the uterine tube lead to local inflammatory ration and block

the tube.

o If the female want to become pregnant again  do IVF.

 Bilateral male vasiectomy:

o  Incision in the scrotum.
o  Cut the vas deferens.
o  The male become infertile after 3 months.
o  Should do semen analysis for at least 3 times to confirm the success of the

operation.

Subject7: Infertility

Definition:

 It is failure to get pregnant after 1-2 years with regular unprotected sexual activity.

Causes:

  Ovulatory factor  PCOS.
  Tubal factor  Obstruction.
  Endometrial factor.
  Unexplained.
  Testicular factor.

History in female:

 Age:

o Natural conception declines significantly in the female after 35 years of age. This is

due to the decline in oocyte quality and numbers.

o Ask about mirage before menarche.

 History of getting pregnant before  to know if it is primary or secondary infertility.
 Duration of infertility  to know the cause, to know if it is primary or secondary

infertility.

 Body weight  Over or under weight can affect ovulation (irregular cycle, PCOS);

women with a body mass index (BMI) of >29 or <19 will have difficulty conceiving.

  Hair distribution  Hirsutism (PCOS).
  Body temperature  elevated due to progesterone.
  Menstrual cycle  regular or irregular (indicate ovulatory cause), LMP, mid-cyclic pain.
  Gynecological history  pap smear, ectopic, PCOS, inter-menstrual bleeding.
  Type of contraception  Injectable (lead to increase period of non-pregnant), IUCD

(infection), OCCP (can get pregnant early).

 Occupational hazards  exposure to chemicals and radiation adversely affects male and

female fertility.

  Smoking  reduces fertility in females and semen quality in males.
  Alcohol  excessive alcohol is harmful to the fetus, and can also affect sperm quality.
  Drugs:

o  Non-steroidal anti-inflammatory drugs (inhibit ovulation).
o  Chemotherapy (destroys rapidly dividing cells e.g. gametes).
o  Cimetidine, sulphasalazine, androgen injections (affects sperm quality).

 Sexual history:

o Coital frequency  stress and anxiety may affect libido and coital frequency and

thus impact on fertility. Recommended coital frequency is two to three times per
week.

o Post-coital bleeding.
o Sexual transmitted diseases (STDs).

 Medical history  chronic diseases, IBD.
 Surgical history  appendectomy could lead to adhesion of the uterine tube, trauma

like car accident.

 Family history  infertility, PCOS, congenital abnormalities.

History in male:

  Age  fertile up to 80 years.
  Number of wives.
  Occupation  radiation, excessive heat, away from house.
  History of illegal relationships  STDs lead to tubal diseases.
  Medical history  trauma, DM, hypertension.
  Surgical history  hydrocele, torsion.
  History of undescended testes or mumps.
  Drugs that lead to impotence.

Examination:

 General examination  weight, hirsutism, vital sings, sign of any medical diseases

(thyroid, DM, autoimmune diseases).

 Abdominal examination  striae (indicate previous pregnancy), mass (ovarian or

fibroid), scar, hair distribution.

 Genital examination  abnormal discharge, pus.
 Bi-valve speculum  excoriation, redness, ulcer, erosions, abnormal discharge, high

vaginal swap, endo-cervical swap.

 Digital examination (bi-pelvic examination)  uterus (size, shape, mobility, consistency),

cervix (mass, ectopic, infection, movement lead to severe pain = cervical excitation
test), fornex (feel the adenxae -ovary and tube- normally not palpable).

 Examination in male:

o General examination  sign of any medical diseases.
o Local examination of the genitalia.

Investigations:

 Ultrasound  in regular cycle do US before day 14 (in day 12 or 13) to see the follicles

before rapture // By US see ovarian cyst, size of ovaries in mid-cyclic time, rapture of the
follicles.

 Hormonal assay  LH and FSH (do at day 2 or 3 -this is baseline-), do Prolactin test at

any time (irregular cycle, unovulatory cycle), Progesterone (do it at the end of the cycle
at day 22 in the mid-luteal phase, high level of progesterone confirm the presence of
corpus luteum).

 Laparoscope  diagnostic and therapeutic, see endometriosis or tubal adhesion.
 hHistosalpingography  inject radiopaque dye then take x-ray, normally see white tube

with spillage at the end of the tube>

 For ovary cause  do US and hormonal assay.
 For tubal cause  do laparoscope and histosalpingography (filling defect, obstruction,

other diseases).

 In male  seminal analysis  see this table

about normal parameters for semen analysis
according to WHO criteria.

Treatment:

 If there is ovulatory cause  stimulate the ovulation by clomiphene citrate  give it at

day2 of the cycle and continue for 5 days, start by low dose, follow up by US.

 If the cause is ovulatory  use pregnin lead to LH surge, called ابرة مفجرة, lead to

rapture of follicles, give it when follicles are well-developed, its action begin after 48
hours.

 Life style modification  nutrition, weight, exercise.

Subject8: Fibroid

Information:

  A fibroid is a benign tumor of uterine smooth muscle, termed a ‘leiomyoma’.
  2 of 10 females have fibroid.
  The gross appearance is of a firm, whorled tumor.
  The typical whorled appearance may be altered following degeneration; three forms of

which are recognized: red, hyaline and cystic.

 Fibroids are estrogen dependent.
 Risk factors for clinically significant fibroids  nulliparity, obesity, a positive family

history, African racial origin (three times higher risk).

Types:

 Submucous fibroid  Located adjacent to and bulging into

the endometrial cavity.

 Intramural fibroid  Located centrally within the

myometrium.

 Subserosal fibroid  Located at the outer border of the

myometrium.

 Pedunculated fibroid  Attached to the uterus by a

narrow pedicle containing blood vessels.

 Cervical fibroids  arise from the cervix.

History:

In non-pregnant women:

 Asymptomatic when the fibroid is small.
 History of abnormal vaginal bleeding like menorrhagia, inter-menstrual bleeding (if

pediculated), dysmenorrhea.

 Vaginal discharge if infected.
 Pressure symptoms  pressure on bladder lead to frequency, retention of urine /

pressure on the veins lead to varicose veins / pressure on genitalia lead to prolapse.

  Subfertility may result from mechanical distortion or occlusion of the Fallopian tubes.
  Anemia (if there is vaginal bleeding).
  Polycythemia (if there is pressure on the broad ligaments).

In pregnancy:

  Could lead to abortion.
  Pre-term labor.
  Placental abruption.
  Mal-position, mal-presentation.

  Obstructed labor.
  Post-partum hemorrhage due to inefficient uterine contraction.
  Pain due to complications like red-degeneration.

Examination:

 Abdominal mass  by bi-manual examination (adnexa examination  if mobile it is

ovarian mass – if fixed to the uterus it is fibroid).

 Different by pregnancy  there is fundal height like pregnancy but there is no fetal

heart (fetal heart = double maternal pulse).

Investigations:

 Hemoglobin concentration will help to indicate

anemia if there is clinically significant
menorrhagia.

 Ultrasonography is the mainstay of diagnosis to

distinguish between a fibroid and an ovarian
mass.

 In the presence of large fibroids,

ultrasonography is helpful to exclude
hydronephrosis from pressure on the ureters.

Treatment:

 Conservative management is appropriate where asymptomatic fibroids are detected

incidentally.

 The main types of medical treatment for heavy menstrual bleeding (tranexemic acid,

mefenamic acid, combined oral contraceptive pill) tend to be ineffective.

 The only effective medical treatment is to use gonadotrophin releasing hormone (GnRH)

agonists.

 Mifepristone (an antiprogestogen) has been shown to be effective in shrinking fibroids

at a low dose, but is currently not available for use as it causes endometrial hyperplasia.

 Menorrhagia associated with a submucous fibroid or fibroid polyp should be treated by

hysteroscopic removal.

 Where a bulky fibroid uterus causes pressure symptoms, the options are myomectomy

with uterine conservation, or hysterectomy.

 Myomectomy will be the preferred option where preservation of fertility is required.
 Uterine artery embolization (UAE) is a newer technique performed by interventional

radiologists.

 Hysterectomy and myomectomy can be facilitated by GnRH agonist pretreatment over a

three-month period to reduce the bulk and vascularity of the fibroids.

 Description  White yellow, no blood inside, round,

regular, different in size.

 Types of fibroid that interfere with pregnancy 

submucus, intrameural.

 Symptoms  vaginal bleeding, infertility, spontaneous

abortion, pain, pressure effect.

 Treatment  hysterectomy, myomectomy.
 Treatment depend on  type of fibroid, number of

fibroid, symptoms, patient wish, family number.

Multiple fibroid of different size.

Laparoscopy showing multiple fibroids.

Multiple – round – regular outline – from uterus.

Big  submucus fibroid – lead to infertility.
Small  subserous, intramural.

Tx: by myomectomy.

Subject9: Endometriosis

 Endometriosis is the presence of endometrial-like tissue outside the uterine cavity,

which induces a chronic inflammatory reaction. It can occur in various pelvic sites such
as on the ovaries, fallopian tubes, vagina, cervix, or uterosacral ligaments or in the
rectovaginal septum.

 It can also occur in distant sites including laparotomy scars, pleura, lung, diaphragm,

kidney, spleen, gall bladder, nasal mucosa, spinal canal, stomach, and breast.

 Symptoms  Dysmenorrhea, Heavy or irregular bleeding, Pelvic pain, Lower abdominal

or back pain, infertility, Dyschezia, Bloating, nausea, vomiting, Inguinal pain, Pain on
micturition and/or urinary frequency, Pain during exercise.

 Physical examination  nonspecific pelvic tenderness, Ovarian involvement may

present with adnexal tenderness or masses, fixed uterine retroversion.

 Risk factors  Family history of endometriosis, Early age of menarche, Short menstrual

cycles (<27 d), Long duration of menstrual flow (>7 d), Heavy bleeding during menses,
Inverse relationship to parity, Delayed childbearing, Defects in the uterus or fallopian
tubes, Hypoxia and iron deficiency may contribute to the early onset of endometriosis.

 Investigation  Laparoscopy with biopsy is the only definitive way to diagnose

endometriosis.

 Differential diagnosis  Chronic salpingo-oopheritis, Ovarian cyst, malignant ovarian

tumours, Small myoma, Acute abdomen.

 Medical treatment  NSAID, Oral contraceptive pills, Danazol, Gestrinone,

Progestagens, Gonadotrophine releasing hormone agonists.

 Surgical treatment  conservative surgery (LASER, Co2 diathermy, Drainage of

endometriotic cyst), Definitive surgery (TAH + BSO).

Adenomyosis:

  It is a disorder in which endometrial glands are found deep within the myometrium.
  Patients are usually multioparous, in their late thirties or early forties.
  Present usually with severe congestive dysmenorrhoea menorrhagia.
  On examination the uterus is bulky, tender.
  USS: altered ecchogenisity in myometrium, similar to uterine fibroid.
  Treatment: danazole, GnRHa.
  TAH.

Question form the doctor  Patient presented with
irregular bleeding, dyspareunia, on examination she
had a fixed extroverted uterus:

Dx: endometriosis.

Subject10: Ovarian cyst

Types:

1- Benign (95%):

 Could be pre-menopausal or post-menopausal.
 Follicles not raptured then increase or decrease in size and called graafian follicular cyst,

and it is contain fluid.

 Rapture of the follicles lead to corpus luteal cyst, it contain fluid, this cyst can disappear

in the next few cycles.

 Hemorrhagic cyst which contain blood.

2- Malignant: like ovarian carcinoma.

3- Pathological: like polycystic ovarian syndrome (PCO).

Clinical manifestations of benign cyst:

  Small cyst is asymptomatic.
  Gradual abdominal distention.
  Lower abdominal pain.
  Irregular cycles (due to hormonal disturbances).
  Breast tenderness (due to hormonal disturbances).
  Frequency.
  Altered bowel habits.
  Hirsutism.
  Easily fatigability.
  Weight gain.

Examination:

1- General examination.

2- Vital signs.

3- Pelvic examination: fullness of the fornices.

4- Abdominal examination:

  Inspection: distention, dilated veins, hair, striae.
  Palpation: small cyst is not palpable, large cyst like mass and it is big and regular.
  Percussion and Auscultation.

Investigations:

  Hb level  differentiate between cyst and cancer (which lead to anemia).
  Blood group and Rh.
  Ultrasound of the abdomen  ultrasound features of the benign cyst are: regular

outline, smooth, no sepitation, no nucleation, no hemorrhage, no calcifications, thin
wall, contain homogenous radiolucent fluid.

  CT / MRI  MRI is better because this cyst is soft mass.
  Hormonal investigations  LH and FSH level.
  Cancer markers  CA-125.

Treatment:

 Less than 3 cm  resolve spontaneously during 2-3 months (cycles).
 Persistent for 2-3 months  use combined oral contraceptive pills (COCP) which reduce

the breast tenderness and suppress the ovulation so decrease the number of follicles
and cysts.

 Cyst with symptoms  like pain, give pain killer and COCP.
 Large symptomatic cyst  surgical removal by laparotomy and take biopsy to exclude

malignancy.

 Malignant cyst  surgery with radiotherapy or chemotherapy.

US sound of uterus:
  Thickness of endometrium = 3-4 mm.
  Regular, thin wall.
  Single echogenicity.
  No blood inside, only fluid.
Dx  simple ovarian cyst.

Huge simple ovarian cyst.
Cancer not reach this size.

Cyst:
Multilocular, thick wall, sometimes bleeding inside.
Could be cancer.

Subject11: Polycystic Ovarian Syndrome (PCOS)

Introduction:

 PCOS is a syndrome of ovarian dysfunction along with the cardinal features of

hyperandrogenism and polycystic ovary morphology.

 The etiology of PCOS is not completely clear, but there is often a family history. It seems

likely that a gene is important in its development.

 Proliferative phase of the cycle  follicles increase in size to become mature (16-18

mm) under the effect of FSH.

  LH  lead to rapture of follicles  give oocyte + follicular fluid.
  Follicular fluid could lead to peritoneal irritation and presented as mid-cyclic pain.
  In PCOS  follicles not reach maturity (biggest follicle is less than 8 mm) so it lead to un-

ovulatory cycle and infertility.

 PCOS  follicles doesn’t contain ova or oocyte so discover it surgically or during IVF (in

vitro fertilization).

Diagnosis of PCOS:

Patients must have two out of the three features below:

1- Clinical features:

  May be asymptomatic.
  Endocrine and metabolic symptoms  could lead to D.M.
  Menstrual abnormality  oligomenorrhoea, amenorrhoea,
  Hirsutism and acne and balding.
  Subfertility in up to 75 per cent of women.
  Weight gain and Obesity.
  Recurrent miscarriage.
  Acanthosis nigricans  areas of increased velvety skin pigmentation occur in the axillae

and other flexures.

2- Biochemical features:

  Increased free testosterone.
  LH/FSH more than 3 (reversed ratio).
  Increase insulin (impaired glucose tolerance).
  Decrease level of sex hormone binding globulin.

3- Image features:

 Ultrasound  more than 10 hypoechoic follicles, each measure 6-8 mm in diameter,

with or without increase ovarian volume.

 Laparoscopy  big size ovary, could be bilateral.

Investigation:

  Investigate for same hormones mentioned above.
  Glucose tolerance test.
  Imaging study.

Treatment:

1- Education of patient.

2- Conservative:

  Contraception: give OCCP.
  Metformin: for D.M.
  Weight reduction: to reduce to peripheral conversion in adipose tissue  decrease

androgen  can lead to increase size of follicles  Pregnancy can occur.

3- Medication:

 Symptomatic relieve by anti-androgens.
 Ovulation induction (to get pregnant) by giving clomifine citrate 50-150 mg/day, start

from mid of the cycle and still for 5 days. // side effect of ovulation induction is OHSS
"ovarian hyper-stimulation syndrome" which need hospital admission.

Note: give OCCP  rest the ovary for 3 months  then do ovulation induction.

4- Surgery:

 Cut part of the ovary  wedge resection.
 IVF  remove all follicles then make IVF and give fixator.

=============================================

Question form doctor:

Patient presented with irregular bleeding and have this
sonography:

 Sonography: bliateral ovaries contain more than 10

follicles each measure 2-5 mm arranged in necklace
apperance, and there is increased ovarian stroma
with or without increased of ovarian volume more
than 10 cm3.

 Diagnosis: polycyctic ovarian syndome.
 Other symotms: hirsutism, obesity, acne.

 Other menstural abnormality: oligomenorrhea or amenorrhea.
 Investigations: Increased free testosterone, LH/FSH more than 3 (reversed ratio),

Increase insulin (impaired glucose tolerance), Decrease level of sex hormone binding
globulin.

 Treatment: medical (COCP, ovulation induction), surgical, weight reduction.

What is this procedure :
wedge resection part of
surgical tx in case of PCOS

Subject12: Ovarian neoplasia

Investigations:

  TVS –masses and mass characteristics
  Tumor markers – CA-125, LPA (plasmalysophosphatidic acid)
  CT – assess spread to LN, pelvic and abdominal structures
  MRI – best for distinguishing malignant from benign tumors

Symptoms:

 Functioning tumors.
 Nonfunctioning tumors  swelling, pressure symptoms, pain, menstrual disturbances,

ovarian cachexia

The following suggest malignancy:

 age: mostly postmenopausal

  pain: chronic and persistent
  rapid course
  bilaterality
  Solidity ( variegated consistency )
  fixity
  metastases :nodules in DP, lymph nodes
  ascitis
  edema LL
  cachexia

Treatment:

 Depends on  Staging, Tumor type, Age, Desire for future fertility
 Complete surgery: TAH/BSO + omentectomy + lymphadenectomy:

o other cases of stage Ia

 Conservative surgery: unilateral adnexectomy indicated:

o  stage Ia: intact capsule, negative peritoneal washing, free omentum,
o  well differentiated T,
o  young patient with low parity
o  Stage Ib,c

 Cytoreductive surgery: TAH/BSO + omentectomy + lymphadenectomy + may be bowel

resection & anastomosis:

o for all other stages

 Chemotherapy.
 Radiotherapy.

Subject13: Endometrial carcinoma

Risk factors for Endometrial Cancer:

  high levels of estrogen
  endometrial hyperplasia
  obesity
  hypertension
  polycystic ovary syndrome[citation needed]
  nulliparity (never having carried a pregnancy)

  infertility (inability to become pregnant)
  early menarche (onset of menstruation)
  late menopause (cessation of menstruation)
  endometrial polyps or other benign growths of the

uterine lining

  diabetes
  Tamoxifen
  high intake of animal fat[citation needed]
  pelvic radiation therapy
  breast cancer
  ovarian cancer
  heavy daily alcohol consumption (possibly a risk factor)

Factors reduce risk of endometrial carcinoma

  Oral contraception.
  Progestogens.
  Smoking.

Clinical presentation

 Post-menopausal bleeding, Intermenstrual bleeding,

menorrhagia, Watery or purulent vaginal discharge (blood stained), Pain, Abnormal
screening test.

Investigations 

Pap smear, Endometrial curettage, dilation and curettage (D&C),

Hysteroscopy, Endometrial biopsy or aspiration, Transvaginal ultrasound,
Sonohysterography, Pipelle biopsy curettage, TruTest, Magnetic resonance imaging (MRI).

Spread Patterns 

Direct extension, Transtubal, Lymphatic, Hematogenous (Lung most

common, Liver, brain, bone)

Treatment:

  Stage IB or less: total hyst/BSO/PPALND, cytology
  Stage IC to IIB: total hyst/BSO/PPALND, cytology, adjuvant pelvic XRT
  Stage III: total hyst/BSO/PPALND, cytology, adjuvant chemotherapy
  Stage IV: palliative XRT and chemotherapy

Subject14: Premalignant condition of the cervix

Screening for cervical intraepithelial neoplasia (CIN):

 Medical screening method

o  Detect premalignant and malignant processes of cervix.
o  Prevent progression of abnormal cells to cancer.
o  This is NOT a diagnostic test!

 Cervical cancer screening with cytology provides the opportunity for early effective

intervention and has reduced morbidity and mortality

  Papanicolaou
  Cervicoscopey
  Visual inspection with acetic acid (VIA)
  Visual inspection with acetic acid and magnification (VIAM).
  Colposcopy
  Cervicography
  Automated pap smears
  Molecular (HPV/DNA) tests.
  Co-testing using the combination of cytology plus HPV DNA testing is an appropriate

screening test for women older than 30 years (applied in some places).

Papanicolaou (Pap) smear test:

 Is a screening test for asymptomatic Women to detect treatable pre-invasive squamous

abnormalities of the Cervix

  Not diagnostic-rather screening test to detect early changes on the cervix.
  It is a simple and painless test that may cause minor discomfort.
  Cervical Smear aims to prevent cancer, not to detect cancer.
  Cervical cancer screening should begin at age 21 years and not before age 21 because it

may lead to unnecessary and harmful evaluation and treatment in women at very low
risk of cancer.

 Women who have been immunized against HPV-16 and HPV-18 should be screened by

the same regimen as non-immunized women because it doesn’t prevent against all
high risk HPV viral type.

Frequency of cervical cytology screening:

 Annual cervical cytology screening is recommended for women aged 21–29 years.

 Women aged 30 years and older who have had three consecutive cervical cytology test

results that are negative for intraepithelial lesions and malignancy may be screened
every 2-3 years.

 women with any of the following risk factors may still require more frequent cervical

cytology screening:

o  Women who are infected with human immunodeficiency virus (HIV)
o  Women who are immunosuppressed (such as those who have renal transplants).
o  Women who were exposed to diethylstilbestrol in utero.
o  Women previously treated for CIN 2, CIN 3, or cancer (continue to have annual

screening for at least 20 years).

Pap Smear is not necessary in women in these categories:

  Virgin patient.
  Total Hysterectomy for benign disease.
  Recent result of pap smear.
  Age over 65 and over 10 benign Pap Smears.

Preparation:

 To prepare for the Pap test, for two days before the test ,women should avoid:

o  Vaginal Douching .
o  Using tampons.
o  sexual intercourse.
o  Using birth control foams, creams, or jellies or vaginal medications or creams.

 The ideal time for a woman to have a Pap Smear is five days after her menstrual period

has ended.

 Exfoliated cells are collected from the transformation zone of the cervix by Use spatula

of different size or brush.

There are two methods of preparing and processing cervical smear slides:

1. Conventional cervical (Pap) smear test:

 Collecting the cells smears on a microscope slide and

applies a fixative.

 The slide is sent to a laboratory for evaluation.
 The Spatula with the optimal shape and size is

chosen.

 The 'tongue' of the spatula is introduced into the canal, whilst its 'shoulder' is

positioned on the 3 o'clock position of the ectocervix at the beginning of the
procedure . With gentle pressure the spatula is rotated in a clockwise direction.

2. Liquid based cytology (LBC) test.

 Cell transferred to a vial of liquid preservative

that is processed in the laboratory to produce a
slide for interpretation by light microscopy.

Classification of CIN:

CIN classification

 CIN 1 (mild dysplasia) involvement of the inner one-third of the epithelium.

 CIN 2 (moderate dysplasia) involvement of inner one-half to two-third

 CIN 3 (severe dysplasia/carcinoma in situ) full thickness involvement.

Or can be classified as:

 Low grade lesions (CIN1 and HPV-associated changes) in which there is a significant

chance of regression and low progressive potential.

 High grade lesions (CIN 2 and CIN 3) are likely to behave as cancer precursors.

Colposcopy:

 It is a binocular operating microscope

with magnification of 5-20 times.

 Indicated for further investigation of

smear abnormalities.

 It has been used to examine the cervix in

detail to:
*Identify dysplastic abnormalities on the ectocervix.
*Detect changes in the cellular pattern and vascularity of the covering epithelium.
*Allow the accurate localization of the abnormal epithelium.
*Exclude an invasive process.

 Methods:

*Saline method.
*Classical or extended method.
*Iodine test.

Treatment of CIN:

 Destroying the abnormal epithelium (cryosurgery, laser vaporization).
 Excisional techniques:

a.  local excision
b.  loop electrode excision procedure (LEEP).
c.  cone biopsy.
d.  trachelectomy (excision of cervix).
e.  hysterectomy.

 LEEP (loop electrosurgical

excision procedure(: After
freezing the area with local
anesthetic, an electrical wire
loop is inserted into the vagina
and all the abnormal tissue is
removed. This procedure is also
done in the physician's office.

 A cone biopsy: refers to

removal of a cone-shaped
piece of tissue. The tissue
removed provides a more
extensive sample for diagnosis
than a simple biopsy. A cone
biopsy is usually done in the
operating room.

 The cold cone biopsy is a surgical

procedure requiring general anesthesia
and is indicated by the presence of
precancerous changes in the cervix .

Notes form doctor:

 Tools



spatula or cytobrush, slide, cusco speculum, gloves.

 Indications of pap smear:

o For screening of malignant and premalignant conditions.
o For checking degree of infection (HPV- 16-18-31-35).

 What are the pre-request of doing pap-smear:

o  Avoid intercourse for at last 24-48 hours.
o  Avoid use of any vaginal wash or douche.
o  Do pap smear at day 12 of the cycle.

Subject15: Cervical cancer

Causes for cervical cancer:

  human papillomavirus (HPV) infection,
  HIV infection.
  chlamydia infection.
  stress and stress-related disorders.
  dietary factors.
  hormonal contraception.
  multiple pregnancies.
  exposure to the hormonal drug diethylstilbestrol (DES) .
  Smoking.
  family history of cervical cancer.
  There is a possible genetic risk associated with HLA-B7.

Risk groups for cervical cancer:

  Young age at first coitus(20years)
  Multiple sexual partners.
  Young age at first pregnancy.
  High parity .
  Low socioeconomic state.
  Smoking.

Clinical presentations:

  Asymptomatic.
  Vaginal bleeding, contact bleeding.
  Profuse vaginal discharge.
  Cervical mass.
  Moderate pain.
  Fistula formation (leak age of urine or feces).
  Symptoms of distant metastases may be present as enlarged inguinal and

supraclavicular L.N. metastases in the abdomen, lungs or else where in case of
advanced disease.

 Systemic manifestation of advanced malignancy as: loss of appetite, weight loss,

fatigue, pelvic pain, back pain, leg pain, single swollen leg, heavy bleeding from the
vagina, leaking of urine or feces from the vagina, and bone fractures.

Differential diagnosis:

  Cervicitis.
  Cervical ectropion.
  Endometrial carcinoma.
  Pelvic inflammatory disease (PID).
  Vaginal cancer.
  Metastatic cancer to cervix (rare).
  Tuberculosis.
  Syphilitic chancre.
  Choriocarcinoma.

Investigations:

  Diagnosis should be based on histology and appropriate biopsies.
  After the diagnosis is established, investigation which needed are:
  Complete blood cell count
  Renal functions test
  Hepatic functions test
  Imaging Studies: for staging
  Chest radiograph should be obtained to help rule out pulmonary metastasis.
  CT scan of the abdomen and pelvis is performed to look for metastasis in the liver,

lymph nodes, or other organs and to help rule out hydronephrosis/ hydroureter.

 Barium enema (sometimes).
 Intravenous urogram.

Treatment:

 Conization or simple hysterectomy (removal of the uterus) - microinvasive cancer
 Radical hysterectomy - removal of the uterus with its associated connective tissues, the

upper vagina, and pelvic lymph nodes. Ovarian preservation is possible.

 Chemoradiation therapy
 Surgery  should only be considered an option for early disease (stage 1 and stage

11a).

 Early cervical cancers (stage I and IIA) may be treated by either procedure.
 Radiotherapy is the treatment of choice once the disease has spread beyond the

confines of the cervix and vaginal fornices, when surgery is not effective. Stage Ib2-IVa

Subject16: Conditions affecting the vagina and vulva

Causes of vulvar conditions:

  Infection: candida, Trichomonas vaginalis.
  Inflammation: Lichen planus, Lichen sclerosis.
  Trauma: sexual or asexual.
  Drugs.
  Premalignant and malignant conditions.
  Autoimmune: Crohn's disease, Paget's disease.

Infections:

Candida infection:

  Candida albicans  dimorphic yeast.
  Symptoms  pruritus, vaginal discharge (white, cheesy, adherent to vaginal skin).
  Signs  redness, erythema, swelling, macerated skin.

 Investigation  swab.
 Treatment  symptoms control (give alarmin for pruritus), local care, antifungal

(local and systemic).

Trichomonas vaginalis:

 It is protozoa, consider as STD.
 Symptoms  pruritus, discharge (green gray, frothy), soreness which lead to

dyspareunia.

  Signs  redness, swelling, strawberry lesion of vagina and cervix (2% of patients).
  Investigation  wet smear (saline).
  Treatment  for patient and husband, screening for other STD, metronidazole for 2

weeks, local care.

Herpes simplex:

 Genital herpes  caused by HSV-2 and increasingly by HSV-1 (due to oro-genital

sex).

  There is primary and recurrence phases of infection.
  Primary is most severe.
  Symptoms  pain, ulcer, dyspareunia, retention of urine, systemic manifestation

(fever, tired).

  Signs  multiple small elevated ulcers, swelling, erythema.
  Investigations  swab.
  Treatment  local care, analgesia, normal saline path, acyclovir.
  Recurrent infection  less severe and it is prolonged by stress, fever, sexual

intercourse, menstruation.

Human papilloma virus:

  Condition called condyloma acuminatum (DDx: condyloma lata).
  Presentation  skin lumps different in size.
  Treatment  medical or surgical.

Other infections:

 Syphilis.
 Lymphogranuloma venereum.

Inflammatory:

Lichen sclerosis:

  Inflammatory destructive skin valvar condition.
  Could be associated with other skin lesions.
  Cause is unknown but it could be autoimmune.
  In young  self-limited.
  In elderly  premalignant condition, destructive, not self-limited.
  At beginning (erythema, ecchymosis) then (fissuring) then (scaring).
  Signs  narrowing of vaginal opening lead to dyspareunia, scaring of labia minora,

amputation of citreous.

 Investigations  biopsy (indications  erosion, pigmentation, persistent ulcer).
 Treatment:

o  Valvar care: barriers, path.
o  Local steroids (long term)  gradual rate increase.
o  Follow up (because it is premalignant).
o  Rarely need surgery (if narrowing not improved by steroid.

Lichen planus:

 Autoimmune condition.
 Other associated autoimmune diseases  pernicious anemia, type1 DM, thyroid

diseases, Addison's disease.

  Associated with other skin conditions.
  Symptoms  pain, itching, dyspareunia, apareunia, bleeding (post-coital).
  Signs  velvety, Koebner's phenomenon.
  Investigation  biopsy for histopathology (indications  erosion, pigmentation,

persistent ulcer).

 Sometimes it involved the upper respiratory tract, esophagus, external auditory

meatus.

 Treatment  steroid, valvar care.

Hyperkeratosis:

  Cause is chronic trauma.
  Rarely pre-malignant.
  Symptoms  pain, pruritus, dyspareunia.
  Signs  white plaques.
  Investigation  biopsy.
  Treatment  care, removal of cause, steroid.

Dermatitis (eczema):

 Types  Contact dermatitis (only area of contact), allergic dermatitis (any area in the

body).

 Causes of contact dermatitis  soap, bubble path.
 Causes of allergic dermatitis  drugs, hair removal medication (sometimes lead to

contact dermatitis also).

  Symptoms  pain, redness, pruritus, dyspareunia.
  Investigations  skin test (patch test).
  Treatment:

o  Removal of affecting agent.
o  Skin care (barrier).
o  Antihistamine (alarmin).
o  Iodine bicarbonate wash.
o  Steroids.

Psoriasis:

 Occur in flexion of body.
 Features  like psoriasis of other parts in the body.

Premalignant conditions:

Lichen sclerosis in elderly.

Human papilloma virus infection.

Valvar intra-epithelial neoplasm:

 Vulval intraepitheial neoplasia (VIN) is a premalignant skin condition which is

increasing in incidence.

 VIN can be either associated with human papilloma viruses (HPV) or with lichen

sclerosis.

  Stages (dysplasia, one, two, three) like that of cervical cancer.
  Presentation  pain, pigmentation, pruritus, dyspareunia.
  Investigations  biopsy.
  Treatment  palliative therapy (laser cryotherapy), surgical removal and biopsy,

immunotherapy.

 Do assessment of vagina and cervix.

Vulval cancer:

Clinical presentation:

 Vulval cancers usually present with vulval symptoms.
 Patients may present with a lump (noticed when washing), vulval pain (some

tumours are ulcerating) and post-menopausal bleeding (some tumours bleed on
touch). Some patients are frequently unaware of vulval cancer.

 While most tumours are small on examination, it is surprising how large some

tumours can be on initial presentation.

 The tumours are usually clinically obvious and are often cauliflower-type growths on

the vulva.

 Some tumours, however, can ulcerate and some may produce a subtle skin

thickening.

 The most common sites are the labia majora and clitoris and the tumours may be

uni- or multifocal so it is important to examine the patient thoroughly (include the
anal area, vagina and cervix).

 Vulval cancer spreads regionally to the groin nodes (inguinal and femoral) and

palpation of these nodes is important to exclude clinically obvious malignant nodes.

 Patients should also have the cervix inspected to make sure that there is no

involvement by cancer or cervical intraepithelial neoplasia (CIN).

Investigation and the importance of staging:

 A biopsy is essential for diagnosis and a chest x-ray is useful to exclude obvious lung

metastases.

 Staging of the cancer is essential for prognostic information and planning adjuvant

treatment.

 Poor prognostic factors include large (greater than 4 cm) primary tumours, sphincter

involvement and metastases to the groin nodes.

Staging and prognosis of vulval cancer (FIGO 2009):

Treatment:

 Surgical  radical vulvacetomy which include removal of vulva, blilateral L.N

(inguinal and femoral L.Ns).

 Complication of surgery  poor wound healing, wound breakdown, bleeding,

lymphedema, DVT, psychological and sexual problems.

  Radiotherapy  if L.N is involved.
  Sentinel L.N  if involved give radiotherapy, if not involved do surgery only.
  Early stage tumor  wide local excision.

Conditions that affect vagina:

Vaginal discharge:

 Infection  bacterial vaginosis, Trichomonas,

candida.

 Tumors  of vagina, cervix, uterus.
 Other  F.B, trauma.

Lichen planus:

  Involve vagina.
  Give steroids suppositories and vaginal cream.
  Lichen sclerosis: not involve the vagina.

Premalignant conditions:

  Intraepithelial neoplasia can affect the genital tract (CIN and VIN).
  Premalignant and malignant disease of the cervix.
  The vaginal area can also be affected (called vaginal intraepithelial neoplasia, VAIN).
  This is usually as a result of extension of CIN from the cervix.
  VAIN is asymptomatic.
  Treatment can involve cauterization, surgical excision, radiotherapy and

observational follow up depending on the patient, grade of disease and size of the
lesion.

 VAIN assessment and treatment can be complicated and is best managed by

specialist teams.

 There is a risk of vaginal cancer in untreated patients, but this risk remains unclear.

Malignant condition:

 Will be missed so presented later and in metastatic state.
 Treatment: radiation.

FIGO staging and prognosis of
vaginal cancer

Subject17: Urinary incontinence

Classification:

 Stress incontinence (most common): involuntary loss of urine with physical effort

(cough, jump).

 Urge incontinence: involuntary loss of urine associated with urgency.
 Overflow incontinence: precede by contraction then full of bladder then

incontinence.

 Continuous incontinence: always loss of urine without provoking factors.

Symptoms:

Symptoms before voiding (storage phase):

  Stress incontinence.
  Urge incontinence.
  Urgency: intense desire to void.
  Frequency: urination more than usual voiding rate.
  Decrease or increase bladder sensation of fullness.

Symptoms during voiding (void phase):

  Poor stream (voiding difficulty).
  Intermittent stream.
  Hesitancy.

Symptoms after voiding (post voiding phase):

  Post voiding drippling of urine (most common cause is urethral diverticulum).
  Feeling of incomplete emptying.
  Dysuria, hematuria, pyuria.

Investigations:
1- Local:

 Mid-stream urine examination (infection  treat it).
 Urinary diary test (chart for input and output, episodes of incontinence, provoked

factors).

 Pad test (weight the pad then do physical activities that lead to incontinence for 4

hours then weight the pad, if increased by 1 g it considered as significant
incontinence).

 Three swab test:

o Put three swabs in the vagina, inject the methylene blue in bladder, then wait for

time.

o  Upper swab stain  vesico-vaginal fistula.
o  Middle swab stain  urethra-vaginal fistula.
o  Lower swab stain  incontinence or contamination.
o  Wet but not stain  urethra-vaginal fistula.

2- Urodynamic study:

 Flowmetery:

o  Voiding (ml) per time (min).
o  Normal  half of bladder = 50 ml/sec.
o  Detrusor pressure = pressure inside bladder – intra-abdominal pressure.
o  Storage phase  first desire to void = half of bladder capacity = 150-200 ml

normally.

o  Bladder capacity = 400-600 ml normally.
o  Detrusor pressure = less than 15 ml of water.
o  No involuntary loss of urine.
o  Ask the patient to void normally 50 ml/sec and detrusor pressure during voiding

= 70.

o Residual volume = less than 50 ml normally.
o Benefits  know the bladder capacity, stress incontinence, detrusor pressure,

obstruction, residual volume.

o Indications of flowmetery:

  Before operation.
  Neurogenic bladder.
  Multiple symptoms (urge and stress).
  Multiple sclerosis.
  Voiding problems.
  Fail of operation.

 Vedio-cystourethrography:

o Radioactive material and take colored films.
o Useful to see  diverticula, fistula, reflux, same indications of flowmetery.

3- Radiological tests:

 US  Residual volume, bladder (stones, mass), diverticulum, mass in abdomen,

kidney.

 IVU.
 MRI  problems in pelvic floor or sphinceter.

4- Tests for sphincter:

 Nerve conduction study.
 Urethral pressure profiometery.

Management:

1- Overflow insentience:

 Treated by urologist and neurologist.
 End by continuous catheter.

2- Stress incontinence:

  Pelvic floor exercise.
  Pelvic floor muscle stimulation.
  Vaginal cone.
  Drugs: SSRI (lead to nausea and vomiting).
  Surgery:

o  Colpo suspension.
o  TPT.
o  Artificial sphincter.
o  Local injection of strengthening materials like collagen.

3- Detrusor overactivity:

 Bladder training:
 Drugs:

o  Selective anticholinergic.
o  TCA.
o  Anti-diuretics (decrease urine output).
o  Gabapentin (for neurogenic bladder).

 Surgery:

o Sacral nerve stimulation.
o Tibial nerve stimulation.

 Use pat or catheterization (suprapubic or self).

Subject18: Prolapse

Introduction:

 It is protrusion of uterus or pelvic organs (bladder, rectum) in to or outside the vagina.
 It occur due to lack or weakness of supporting structures like connective tissue, muscles,

ligaments that support the pelvic organs.

 You can use Sim's speculum to see anterior and posterior vaginal wall  see the

protrusion.

Causes:

 Childbirth and raised intra-abdominal pressure

 Aging  the process of ageing can result in loss of collagen and weakness of fascia and

connective tissue.

  Multiple parity  lead to increase laxity of the ligaments.
  Obstructed labor  lead to weakness of the supporting structures.
  Congenital  connective tissue defects like collagen diseases.
  Lack of estrogen  lead to atrophy and increase laxity.
  After hysterectomy  because we cut the ligaments.

Types:

  Cystocele  prolapse of the urinary bladder.
  Urethrocele  prolapse of the urethra.
  Rectocele  prolapse of the rectum.
  Enterocele  prolapse of the part of the small intestine.
  Uterine prolapse  prolapse of the uterus.

Symptoms:

 Non-specific:

o Lump, local discomfort, backache, bleeding/ infection if ulcerated, dyspareunia or

apareunia.

o Rarely, in extremely severe cystourethrocele, uterovaginal or vault prolapse, renal

failure may occur as a result of ureteric kinking.

 Specific:

o Cystourethrocele – urinary frequency and urgency, voiding difficulty, urinary tract

infection, stress incontinence.

o Rectocele: incomplete bowel emptying, digitation, splinting, passive anal

incontinence.

Symptoms

Cystocele or urethrocele:

  Could be due to frequent pregnancies.
  Lead to urinary symptoms like urgency, frequency, infection (cystitis, UTI).
  General and abdominal examination show nothing important.
  Pelvic examination  ask the patient to come with full bladder, examine the patient in

dorsal position, good lightening, use sim's speculum  see bulging  ask patient to
cough and this lead to increase the bulging of cystocele and see few drops of urine pass
through the urethra.

Note: lithotomy position means labor position, dorsal position means patient lye on her
back.

Rectocele or enterocele:

 Protrusion lead to bulging in the posterior vaginal wall.
 Symptoms: difficulty in defecation, stasis, constipation, painful defecation.

Uterine protrusion:

  Usually presented in menopause.
  Not affect the cycle.
  Symptoms: felling of heaviness in the pelvis, friction lead to ulceration and infection,

bleeding on touch.

Grades:

  Grade1: the uterus reach the vagina.
  Grade2: the uterus reach the introitus.
  Grade3: uterus and cervix outside the vagina.
  Procidentia = complete prolapse = Grade3

Score:

Baden Walker Hoffman score (2013)

 Zero station  at the level of Ischial spine ((there is no

prolapse at this point))

  Grade1  descend in half way to the hymen.
  Grade2  Reaching the hymen.
  Grade3  half way behind the hymen.
  Grade4  further descend.

Differential diagnosis:

 Anterior wall prolapse  congenital or inclusion dermoid vaginal cyst, urethral

diverticulum.

 Uterovaginal prolapse  large uterine polyp.

Management:

  History.
  Examination.
  Investigations:

o Cystocele  general urine examination, urine microscopy, cystometry,

cystoscopy, urethroscopy, urodynamic study.

o Rectocele  sigmoidoscopy (DDx  tumor like fibroma), anoscopy.
o Uterine prolapse  ulcer swab.

 Treatment.

Treatment:

1- Hormonal replacement therapy  give low dose tab of estrogen  used in minor
prolapse.

2- Treat the infection.

3- Electrical stimulation of the pelvic floor  will strength the floor  used in minor
prolapse.

4- Pessary (ring pessary):

 There are multiple types and shapes color and sizes of

pessary.

 Used if patient above 60 years and not fit for

anesthesia or have multiple diseases.

 Push the uterus to its normal site then fit the ring

between the anterior and posterior vaginal wall.

 The ring pessary still 3-6 months then take it off and clean and sterilize it and put it

again.

 Prolonged period of pessary lead to infection, ulcer, pressure.

5- Vaginal or abdominal hysterectomy  used for patient complete her family, fit for
surgery, has procidentia (complete prolapse).

6- Patient  young age, not complete her family, has uterine prolapse or other types of
prolapse:

 Repair of wall  like anterior or posterior colporaphy or both.
 Surgery  fixing the ligament by uterosacral fixing (use mish between sacrum and

uterus).

Prophylaxis:

  Exercise after delivery (pelvic flow examination).
  Avoid prolongation of labor especially during second stage of labor.
  Reduce the number of traumatic delivery.

General notes:

 Bartholin cyst  it is swelling of the bartholin duct which open between labia minora

and hymen  + infection  bartholin abscess.  Treated by drainage and
marsupialization.

 The pregnancy is confirmed by blood test in 3-5 days and by blood test in 10 days.
 ICUD = used for 5 years  carry risk of bleeding (menorrhea), infection (in first 2

weeks), pregnancy (when fall).

Notes form doctor:

 Cystocele:

o  Occur in old age.
o  History of incontenince.
o  Ask patient to come with full bladder.
o  Ask the patient to cough.

 Ring pessary:

o  Used to treat prolapse.
o  Put for 6 months.
o  Complications  ulceration, infection.

Subject19: Abnormal vaginal discharge

Infection:

 Upper and lower genital tract infection.
 Most of abnormal vaginal discharge is due to lower infection because it is more

common.

 Infection of lower genital tract  candida albicans (vulvo-vaginal candidiasis),

Trichomnias vaginals, bacterial vaginosis.

 Candida  discharge (white color, malodor, thick like cheese, adherent and difficult to

separate form vulvar skin) – itching – soreness.

 T. vaginalis  discharge (gray-greenish in color, frothy) – itching – soreness.
 Bacterial vaginosis  discharge (whitish-gray in color, bad fishy odor) – no itching – no

soreness.

Examination:

  Candidiasis  red macerated skin of vulva and vagina.
  T. vaginalis  red inflamed and strawberry vagina.
  Bacterial vaginosis  normal (because it is not inflammation, but there is only chage in

the bacterial flora).

Upper genital tract infection (pelvic inflammatory diseases PID):

 Symptoms  fever, abdominal pain, deep dyspareunia (superficial in lower infection),

diarrhea, vomiting, dysuria, frequency, abdominal tenderness, toxic state, adnexal mass
(abscess), vaginal discharge (without any characteristics), inter-menstrual bleeding,
menorrhagia, dysmenorrhea.

Diagnosis:

 Candida  culture and sensitivity.
 T. vaginalis  wet filed using normal saline and microscope to see tichomonus with its

four flagella and undulant membrane.

 Bacterial vaginosis  Criteria  Discharge (whitish-gray, fishy odor), Ph (high, more

than 4.5), KOH (fish odor), Clue cell (by microscope).

Management:

  Candida  nystatin, clotrimazole antifungal.
  Trichomias  metronidazole.
  Bacterial vaginosis  metronidazole.
  Upper genital tract  any antibiotic.
  Symptomatic treatment  analgesic, anti-piratic.
  Bed-rest.
  STDs  prevent sexual intercourse, treat the partner, search for partner infected,

search for other STDs.

Key Points:

  Acute PID can be life threatening.
  Other differential diagnosis should be kept in mind (ectopic pregnancy, appendicitis).
  Detailed sexual history should be taken.
  Incomplete treatment of sexually transmitted infections should be avoided as there is a

high chance of recurrence.

 Surgical treatment should not be delayed if patient’s general condition is not improving

with conservative treatment.

 Thorough counselling regarding the implications of infection with regards to subfertility

and risk of ectopic pregnancy should be offered.

 All attempts to contact present and previous partners should be encouraged and made.
 Patients should be advised to use barrier contraception until the infection is completely

cured. Test of cure should be done.

Candidiasis

Trichomonas

Bacterial vaginosis

Chlamydia

Gonorrhea

Upper genital infection

Subject20: Gestational trophoblastic disease

Association:

  Younger age group less than 16 years and more than 40 years.
  Areas: Asians.
  History of previous mole.
  Nutritional factors: carotene deficiency.

Partial mole:

 Triploid (3 sets of chromosome = 69).
 Due to fertilization of 2 sperms to one ovum or fertilization of one divided sperm to one

ovum.

  Fetal vessels and placenta present.
  There is focal hydropic degeneration in placenta.
  Presentation: abortion.
  Diagnosed by histopathological study.
  Need for chemotherapy (0.5%).

H.mole:

  46 chromosome.
  Only paternal chromosome (2 sperms or one divided sperm).
  Usually xx.
  No feral vessels.
  Presence of villi with hydropic degeneration.
  Presentation: excessive symptoms of pregnancy like pre-eclampsia, thyroid

enlargement, large uterus.

 50% need chemotherapy.
 Diagnosed by US  snow storm appearance due to excessive cystic lesions.

Management of partial mole and H.mole:

Evacuation:

 Preparation: prepare blood, investigation (CBC, Hb, blood group, cross match, B-hCG).
 General ansthesia.

 Suction method if evacuation.
 If bleeding occur  not use oxytocin but use ergometrine at the end of evacuation.

Follow up:

  Twice weekly for 6 months.
  Avoid pregnancy to avoid confusion.
  Better not use COCP  cause slower lowering of B-hCG.
  Better not use IUCD or progesterone  they lead to bleeding and confusion.
  Best method is condom.
  Contraception for 6 months if not use chemotherapy.
  Contraception for 1 year if use chemotherapy.

Chemotherapy.

Figo scoring or staging:

 Age of patient  less than 40 years is low risk, more than 40 years is high risk.
 Previous pregnancy before the mole  H.mole (low risk), abortion (moderate risk),

normal pregnancy (high risk).

 Duration between H.mole and pregnancy  less than 3 months (low risk), more than 1

year (high risk).

  Level of B-hCG  1000 (low risk), 1000000 (high risk).
  Site of metastasis  lung (low risk), brain (high risk).
  Number of metastasis  large number (high risk), low number (low risk).
  Size of metastasis  small size (low risk), large size (high risk).
  Previous chemotherapy  if not take (low risk), if take (high risk).

=== Figo scoring: less than 6 (give one chemotherapy), more than 6 (give multiple
chemotherapy).

Photos: