HYSTERECTOMY

1. Vaginal
Removal of uterus and cervix
 Indications: cystocele, rectocele, uterine prolapse, a
 Prolapse must be obvious and accessible US ligs
 C/I: large fibroid, well supported uterus, endometriosis with intense adhesions
Pedicles:
1) Cervical ligaments
2) Uterosacral ligs
3) Uterine vessels and ligs
4) Infundibulopelvic ligs (ovarian, round, broad)

1. TAH +/- BSO

Removal of uterus and cervix (total) +/- tubes and ovaries
 Indications: chronic pelvic pain, endometriosis, fibroids, irregular periods, menorrhagia, endometrial CA

2. STAH (subtotal abdo hyst) +/- BSO

Remove uterus (leave cervix) +/- tube and ovaries
 Indications: chronic pelvic pain, endometriosis, fibroids, irregular periods, menorrhagia
 Reasons for leaving cervix in situ: Psychological satisfaction of Pt, difficulty removing cervix eg. Adhesion of bladder from previous
multiple CS/abdo surg.
Pedicles:
1) Infundib
2) Uterine
3) US

3. LAVH
Removal of uterus, cervix, +/- tubes and ovaries
To avoid abdo hyst, pedicles can be cut laproscopically and removed vaginally
 Indications: menorrhagia, endometriosis, chronic pelvic pain
 Advantages: Quicker recovery, shorter hospital stay, reduced incidence of post-op complications, cost-effective

NB Don’t remove ovaries if <45y as will cause premature menopause

Complications:
 Immediate: GA complications, bleeding, visceral injury (bladder, bowel, major vessels if abdo; bladder if vag hyst), risk of blood
transfusion
 Short-Late: infxn, pelvic haematoma, urinary retention, DVT, PE, pelvic abscess, pain, paralytic ileus, dyspareunia (if vag hyst)

If Pt doesn’t want hyst, what alternative mgmt. options can you offer?
 If indication is menorrhagia:
- Mirena coil
- Endometrial ablation
- Hormonal: Depo-provera, GnRH analogues
 Long-term risks with GnRH analogues/ depo-provera: osteoporosis
 If indication is prolapse: Pessaries
LAPAROSCOPY/HYSTEROSCOPY
Assessment prior to procedure
 History & general exam
 Pelvic exam
 Pelvic USS
 Menorrhagia/DUB – offer hormonal medications
Veress Needle – at start of laparoscopy
Laparoscopy To be sure you’re in abdo cavity:
Laparoscopy Indications: o 2 clicks (rectus sheath and peritoneum)
o Infertility o Withdraw (shouldn’t get blood or faeces)
o Inject free fluid (palmers test): should get no resistance
o Ovarian cysts
o Ectopic pregnancy Palmers point (LUQ, MCL, 2 finger-breadths below ribs) to avoid adhesions at
o Endometriosis umbilicus if hx of mutple surgeries etc
o Adhesiolysis
o Diagnostic: PCOS, infertility, chronic pelvic pain Trocar: blade withdraws as soon as goes through cavity to avoid visceral
o Irregular period damage
o Dysmenorrhea
Caution: inferior epigastric vessels at risk w/insertion of lateral trocars
Procedure:
 GA
 Insert veress needle into the lower end of umbilicus (below bifurcation of aorta)
 Assess pressure – endure in cavity
 Fill abdominal cavity with CO2 (15-25mmHg)
 Insert trocar and cannula, additional ports as necessary
 Camera (laparoscope) – the ovaries, tubes, pouch, anterior and posterior of the uterus, endometriosis is favorable in the uterosacral
ligament, appendix, and anterior surface of the liver
 Do procedure

Complications
1. GA complications
2. Operative complications (perforation, infection)
3. Surgical emphysema
4. Risk of laparotomy
5. Post-op pain

Hysteroscopy
Hysteroscopy indications
o Endometrial polyps
o Menorrhagia
o Dysmenorrhea
o Post menopausal bleeding
o Infertility
o Suspected uterine malformation

Procedure:
 GA/Spinal
 Lithotomy position
 Insert hysteroscope attached to saline fluid (to distend uterine cavity)
 Visualize the procedure
 Look at the endometrium cavity
o Fundus
o Lateral walls
o Both of the Ostia but not the fallopian tube
o Cervical canal
 Procedures:
o Removal of polyps
o Diagnostic
o Biopsy

Use: holds anterior cervix,

Eg. to facilitate insertion of hysteroscope
through cervix, to bring down uterus in
hysterectomy

Risks: cervical trauma, infxn

PELVIC INFLAMMATORY DISEASE (PID)
Infection of upper genital tract:
o Endometritis
o Salpingitis
o Oophoritis
o Parametritis

Types: Acute, Chronic

Causes:
 Chlamydia (most common STI)
 Gonorrhea
 Mycoplasma
 Staphylococci
 Streptococci
 Bacterial vaginosis

85% Ascending infection from vagina

15% Invasive procedures (hysteroscopy, D+C, IUCDs) *IUCDs a/w Actinomyocosis
<1% Abdominal e.g. infected appendix, bowel perf, abdo abscess

RF:
 Age <25
 Early age at first sexual intercourse
 Multiple sexual partners, marital status (less likely in married)
 Contraception – at risk with OCP/implanon vs barrier contraception. IUCD instertion in preceding 6w
 Previous PID/STI
 TOP – septic abortion
 Smoking

Sx/Si (Acute PID):

 Sx: Lower abdo tenderness, sudden onset pain, foul-smelling vag d/c, fever, malaise, body aches, low appetite, signs of sepsis. May be a/w
vomiting and diarrhoea
 Si: lower abdo tenderness, cervical tenderness, cervical excitation, pyrexia, d/c, flushed genitalia, pelvic USS may show pelvic abscess,
thickened fallopian tubes with increased vascularity
Ix:
 High vaginal swab
 Endocervical swab
 Early morning urine for chlamydia PCR

Mgmt: ABX
 Severe (eg, pelvic abscess) – Admit and IV doxycycline, clindamycin, gentamicin for (7d IV, 7d PO)
 Low risk (no pyrexia, not too much tenderness): doxycycline for 14d or ofloxacin for 14d PO
 Full STI Screen (chlamydia, gonorrhea), MSU chlamydia
 Treat partner in Genitourinary Clinic
 F/U in 4-6/52 +/- repeat high vaginal swab

Long-term Sequelae:
 Chronic pelvic pain
 Infertility
 Ectopic pregnancy
 Recurrent PID
 Dyspareunia
INFECTIOUS DISEASES

CHLAMYDIA
C. trichomatis, obligate intracellular parasite. 3-5% sexually active women
Sx: 70% asymotomatic, PCB/IMB, purulent d/c, abdo/pelvic pain, cervicitis, dysuria
Complications: PID, infertility, ectopic pregnancy, chronic pelvic pain, peri-hepatic adhesions (Fitz-hugh-Curtis Syndrome), reactive arthritis
(Reiters syndrome)
Dx: PCR or endocervical/vulvovaginal swab/1st void urine
Tx: Azithromycin 1g single dose, or Doxycycline 100mg BD x7d, or Erythromycin 500mg BD x14d. Treat partner.
Vertical Transmission: neonatal conjunctivitis, pneumonia

HUMAN PAPILLOMA VIRUS (HPV)

Genital warts (Coldyloma accuminata) – mainly HPV 6 & 11. Clinical Dx, painless lumps in anogenital area.
Tx: nothing, condoms to prevent spread, local tx eg. laser, cryotherapy
Complications: CIN

HERPES
HSV type 1 (orolabial) or 2 (genitals). 10% population has genital herpes. Virus remains dorman in local sensory ganglia, can reactivate.
Sx: painful vulval ulceration, d/c, dysuria, urinary retention, flu-like sx, lymphedema
Dx: typical vesicles & ulcerations of vulva. Viral culture (swab fluid from vesicles)
Mgmt: Aciclovir within 5d of primary onset, analgesia. Secondary occurance: COCP, avoid tampon use, suppressive low dose antiviral

HIV
Retrovirus. Causes immune dysfn by T cell infection.
Ix: PCR (viral RNA), CD4 count
Mgmt: GUM clinic, HAART (↓CD4 + ↑viral load), partner notification
Complications: Kaposi’s sarcoma, non-Hodgkins lymphoma, opportunistic infxn, neuro complications
Post-exposure prohylaxis: triple ART x1mo. Start ASAP (ideally within 1hr). HIV testing @ 3, 6mo

GONORRHOEA
N. gonorrhea: gr –‘ve diplococculs.
Sx: 50% asymptomatic, mucopurilent d/c, lower abdo pain
Complications: PID
Dx: endocervical swab
Tx: Ciprofloxacin
Vertical Transmission: severe neonatal conjunctivitis, sepsis, arthritis

CANDIDA
Candida Albicans. May/may not be sexually transmitted. Can colonize vagina by spread from perineum causing infxn.
RFs: pregnancy, diabetes, COCP, ABX
Sx: vulval itching, soreness, white cheesy d/c, superficial dyspareunia, inflamed vulva/vagina
Tx: clotrimazole (canestan) cream/pessary, or Fluconazole single oral dose

SYPHILIS
Treponoma Pallidum. 9-90d incubation.
Primary: local ulceration (chancre), highly infectious, may be asymptomatic (on cervix)
Secondary: systemic dz, generalized non-itchy lesions
Tertiary: symptomatic. Cardiovascular, neuro, gummatous
Dx: microscopy from ulcer, serological tests
Mgmt: GUM clinic, partner/children screening. Penicillin.
Vertical transmission: congenital syphilis
URINARY INCONTINENCE
Involuntary loss of urine, demonstrable leakage, causing social/hygienic problem
Prevalence: 10-20% of women, ↑ to 25-50% >75y. 1:10 lifetime risk

Types:
1. Stress: loss of urine with activity, e.g. coughing, sneezing, lifting
2. Urge (detrusor overactivity): irresistible desire to pass urine > may be mixed with stress incontinence
3. Overflow (w/ urinary retention) - uncommon
4. True incontinence: fistulae (vesicovaginal/ureterovaginal), congenital abnormalities (ectopic ureter)
*fistula: abnormal communication b/t two epithelial surfaces

Continence maintained at bladder neck – proximal urethral sphincter & proximal urethra
Predisposing factors: Fecal impaction, ↓mobility, confusional states, drugs – diuretics, hypnotics

Ix:
 Hx
o Precipitating events e.g. childbirth
o Lower urinary tract Sx: urgency, freq, nocturia, dysuriam hematuria, enuresis, pelvic pressure, dyspareunia
o Voiding diary (intake/output)
o Meds: diuretics, anti-hypertensives (alpha-blockers)
o Also: neuro hx, obstetric hx, GU hx
 Exam
o Abdo: mass
o Pelvic: prolapse, mass, atrophy, pelvic floor strength
o Rectal: mass, tone, contraction strength, perineal sensation, fecal impaction
o Sacral neuro: sensation, reflex (ankle wink S2-S5, bulbocavernous S2-S3), foot movements, LL muscle strength
 Urinalysis: bacteruria, hematuria, glycosuria, pyuria, proteinuria
 Other tests: post-void residual, stress/cough test, pad test, simple cystometry
 Urodynamic testing: assesses bladder filling & bladder voiding
o Cystometogram (filling assessment): bladder filled w/catheter at 100ml/min, detrusor P = bladder P - abdo P.
 Genuine stress incontinence = leaking w/ ↑abdo P but no change in detrusor P
 Detrusor overactivity / overactive bladder = total bladder P and detrusor P equally elevated
o Uro-Flow monitoring (voiding assessment): vol, peak flow, detrusor activity. Demonstrate residual urine vol.
 Cystourethroscopy

Genuine Stress Incontinence (GSI): leaking of urine with raised intra-abdominal P and absence of detrusor activity
 Weakness of proximal & distal urethral sphincter
Aetiology:
 Pregnancy: denervation of pudendal N. and damage to urethral supporting tissues in vag delivery
 Prolapse: not a cause but deficiency in supporting tissues which cause prolapse also a/w GSI
 Menopause: ↓oestrogen reduces max urethral closure P
 Collagen disorders
 Obesity
Tx:
1. Conservative:
 ↓Intra-abdominal P (weight loss, cough control, treat constipation, avoid heavy lifting)
 Fluid/voiding habits: appropriate fluid intake, avoid caffeine, regular voiding intervals
 Pelvic floor exercises: must be able to contract pelvic muscles
 Bladder training
 Vaginal cones: if unable/minimally able to contact pelvic muscles – provides resistance
 Medication: Duloxetine (SNRI) - ↑pudendal N. activity, strengthening sphincter contraction
2. Surgical:
 TVT: Prolene mesh inserted at mid-urethra, 90% success, complications – urge incontinence, tape too tight, erosion thru
urethra, visceral injury
 Burch Colposuspension: retropubic sutures approximate paravaginal tissues to ileopectineal lig, 80-90% success, complications
– voiding diff, prolapse, detrusor overactivity
 Suburethral slings

Detrusor Over Activity: involuntary contraction of detrusor muscle. Unknown aetiology, occasionally pathological eg. neuropathy (MS
Sx: urgency, urge incontinence, frequency, nocturia (>2/night)
Dx: Hx, Cystometogram
Tx:
1. Behavioural: bladder retraining (void only every 2hrs, extend time by half hourly intervals to progress)
2. Medications:
 Anticholinergics (inhibit acetylcholine which is responsible for detrusor contraction) e.g. Tolteridine (70% improve)
 S/E: dry mouth, blurred vision, constipation
 TCA’s
 Local Oestrogens
3. Surgery: severe Sx, not responsive to conservative
 Cystoscopy + intravesical botox
 Clam ileocystoplasty
 Urinary diversion procudures
PROLAPSE
Protrusion of uterus/vagina beyond normal anatomical confines. May involve bladder, urethra, rectum, bowel.
15-20% multiparous. 2% nulliparous.

Classification:
1. Cystocele: ant vag wall, involving bladder
2. Uterine (apical): uterus, cervix, upper vag
3. Enterocele: upper post vag wal, involving small bowel (pouch of douglas)
4. Rectocele: lower post vag wall, involving rectum

Baden-walker classification: urogenital prolapse (1st -3rd degree) → how far the lowest part descends
1st: slight descent of uterus
2nd: cervix protrudes through introitus
3rd: entire uterus outside vagina → complete procidentia

RF/Causes:
 Vaginal delivery: mechanical injuries & denervation
 Congenital: abnormal collagen metabolism (Ehlers-Danlos)
 Menopause: oestrogen ↓, collagenous connective tissue↓
 ↑intra-abdo P: obesity, pregnancy, chronic cough, constipation
 Iatrogenic: hysterectomy, continence procedures

Sx:
 General: dragging, heaviness, SCD, dyspareunia, discomfort, backache, bleeding d/t excoriation on clothes
 Cystocele: urgerncy, freq, incomplete emptying, ↓flow/retention
 Rectocele: constipation, difficulty w/defecation

Exam:
 Bimanual: exclude masses
 VE: check walls for descent, atrophy & ulceration
 Demonstrate prolapse → LL position w/ Sims
 Standing/straining, stress incontinence
 Pelvic floor muscle strength assessment (grade 0-5)

Ix:
 USS: R/O masses
 MSU
 Blood glucose
 ± Urodynamics
 ± IVP (procidentia)
 ECG, CXR, FBC, U+E: fitness for surgery

Tx:
 Conservative: eliminate ↑abdo P (wt loss, smoking, cough, heavy lifting), pelvic floor exercises, PhysioTx, bladder training
 Pessary
o Ring: Family incomplete, doesn’t want/unfit for surgery. Change every 6mo. Intercourse possible.
o Donut
o Shelf: used when ring/donut fails
 Surgery
o Ant/Post. Colporrhaphy: cystocele, rectocele
o Vaginal hysterectomy: risk of vaginal vault prolapse
o Sacrospinous ligament fixation: for vag vault prolapse (vaginal)
o Colposacroplexy: for vag vault prolapse (abdominal)

Pelvic floor anatomy: Vaginal support

1. Cardinal (transverse cervical) + uterosacral → cervix + upper 1/3 vagj
2. Endopelvic fascia → midportion of vag
3. Levator ani + perineal body → lower 1/3 vag

Pelvic Floor muscles:

1. Levator ani - pubococcygeus, iliococcygeus, puborectalis
2. Obturator internus
3. Priformis
4. Perineal – internal & external
CIN / CERVICAL CA
Develops as a progression of CIN. 1% lifetime risk.
Peak @ 30’s & min 60’s
Types: Squamous cell CA (most common), 15% AdenoCA, Adenosquamous

Cervical screening programme:

Every 3y for 25-44yo, every 5y for 45-60yo. Mid-late follicular phase.
CIN develops in TZ: endocervix (columnar) everts under oestrogen influence → change in pH →metaplasia to squamous, (ectocervix). Sample
of cells taken with cytobrush and suspended in buffer solution. Thin layer on slide,stained w/ Papanicolaou

Smear outcomes:
 Negative smear: normal
 Dyskaryosis: cytological diagnosis of cellular abnormalities. Degrees of dyskaryosis correlate with degree of CIN (histological Dx)
o Mild (CIN 1): repeat smear in 3-6mo, colposcopy if persists
o Moderate (75% CIN2-3): colposcopy
o Severe (80-90% CIN2-3): cells have abnormal maturation & high nuclear:cytoplasmic ratio → colposcopy
 Borderline: occurs w/ HPV, infxn, atrophic vaginitis → repeat smear in 6-12mo. Colposcopy if 3 consecutive borderline smears.
 Atypical glandular cells: possible AdenoCA (endocervix/endometrium) → urgent colposcopy + biopsy

Colposcopy: outpt procedure, cervix examined more closely w/ colposcope (binocular microscope)
 Acetic acid causes protein coagulation and abnormal cells appear white (aceto-white).
 CIN degree identified based on: Degree of aw epithelium, presence of abnormal vasculature, borders of lesion
o CIN 1: faint aw, poorly defined borders
o CIN 2: dense aw, regular borders
o CIN 3: dense aw, well defined borders, abnormal vascular markings, mosaic (if untreated→30% CA over 5-15y)
o Invasive dz: thick aw, punctuations, mosaic, abnormal vaculature w/branching
 Schiller’s test: Lugols iodine stains glycogen brown, abnormal cells have ↓glycogen ∴ stain less

Indications for colposcopy referral:

1. Inadequate Smear x 3
2. Borderline nuclear changes x 3
3. Mild Dyskaryosis x 2
4. Moderate Dyskaryosis x 1
5. Severe Dyskaryosis x 1
6. Any smear that suggests possible invasive cancer
7. Abnormal cervix
8. Women with symptoms: postcoital bleeding, intermenstrual bleeding, persistent vaginal discharge

Mgmt CIN:
1. See & Treat: immediately, based on colposcopic impression
2. Biopsy: to confirm high grade lesion and treat based on results
 LLETZ (Large Loop Excision of Transformation Zone): LA, excision of TZ using diathermy loop, specimen sent for histo analysis
 Cone biopsy: requires GA, large specimen for histo
 Other Tx options (no histo specimens sent): radical electrodiathermy, cryotherapy, laser vaporization, cold coagulation
 F/U: 6monthly smears until 2-3 consecutive normal, then annual smears for 5y, then back on national programme

CIN/Cervical CA RFs:
 HPV: Hx, multiple sexual partners, early onset sexual activity
 Immunosuppression: impaired ability to eliminate HPV eg. HIV, autoimmune dz, immunosupp drugs, T/P pts.
 Smoking

CA Spread:
Local: laterally to parametrium (#1), inf to vag, sup to uterus, ant to bladder, post to rectum
Lymphatic: pelvic→iliac→aortic. Correlates with stage of dz, ie. stage 1 →10% +’ve nodes, stage 3 →35% +’ve nodes

Sx:
 Early dz: asymptomatic, PCB, IMB, PMB, bloody/offensive d/c
 Advanced dz: pelvic pain, back/leg pain (referred), anuria/renal failure (ureteric obstruction), heavy PV bleeding
Si: hard, ireegular, enlarged, possibly ulcerated cervix. Felt on bimanual and seen on speculum

Ix: CT + MRI: to assess spread within pelvis, enlarged nodes, mets (liver)

Staging:
1. Confined to cervix (1a1 invasion upto 3cm, 1a2 invasion 3-3cm, 1b1 diam <4cm, 1b2 diam >4cm)
2. Upper 2/3 vag +/or beyond cervix but not to pelvic side wall (2a no paramet spread, 2b obv paramet spread)
3. Lower 1/3 vag +/or pelvic side wall
4. Beyond true pelvis, involves bladder/rectum
Tx:
1a: cone biopsy w/ regular smear & colposcopy, or hysterectomy Radical (Wertheim) hysterectomy:
1b/2a: radical hysterectomy/radioTx TAH + parametria + upper 1/3 vag + pelvic nodes
2b-4: Radical radioTx ± platinum based chemoTx
Radical RadioTx: combination of EBRT + BrachyTx
ENDOMETRIAL CA
Most common invasive neoplasia of pelvic organs. 4th most common female CA.
95% are carcinomas, 4% sarcomas
Recall
Histological types:  Metaplasia: change from one normal cell type to
 AdenoCA (60-90%) another normal cell type. Eg. transformation
zone (squamocolumnar)
 Adenosquamous
 Dysplasia: change in nucleus/cytoplasm of cell
 Clear cell → pre-cancerous
 Papillary serous  Hyperplasia: ↑prolf. of cells

Sx: PMB (90%), younger pts menstrual disturbance (heavy/irregular)

[1 in 10 pts w/ PMB have endometrial CA or atypical hyperplasia]

RFs:
 Obesity + predispoding factors (T2DM, HTN, hypothyroidism)
 ↓endogenous progesterone production: nulliparity, early menarche + late menopause, PCOS
 Unopposed exogenous oestrogen: HRT, Tamoxifen (oestrogen agonist in endometrial tissue)
 Genetic: HNPCC
 Breast CA: shared lifestyle risk factors and tamoxifen

Spread:
 Direct/local: through myometrium/serosa, down to cervix
 Lymphatic: pelvic, para-aortic, inguinal (rarely)
 Haematological: lungs, liver, bone, barin (rare)
 Peritoneal – particularly papillary serous CA

FIGO Staging:
1. Confined to body of uterus *most Dx @ Stage 1 (75%)
a. Endometrium
b. <50% invasion myometrium
c. >50% invasion myometrium
2. Uterus & Cervix: Cervical stromal invasion, not beyond uterus (endocervical canal)
3. Extrauterine
a. Serosa or adnexa (tubes)
b. Vaginal +/- parametrial
c. Nodes (C1 pelvic, C2 para-aortic)
4. Outside pelvis
a. Bladder/bowel
b. Distant mets

Prognostic indicators: grade of differentiation (G1-G3), and FIGO stage (1-4)

 Overall >75% 5-year survival (98% stage 1, 60% extrauterine spread)

Ix:
 TVUS: assess endometrial thickness (in PMB) – if <5mm and normal ovaries, probability of CA is low
 Endometrial biopsy: eg. pipelle, vabra
 Outpt hysteroscopy +/- biopsy
 Inpt hysteroscopy w/ D+C:

Further Ix (once histoDx confirmed):

 CXR (staging)
 Renal USS or urography
 FBC, U&E, LFT’s
 CT TAP (pre-op staging for G3 dz)
 MRI pelvis: degree of myometrial invasion and status of pelvic/para-aortic nodes

Tx: Refer to cancer centre

 Standard: TAH + BSO ± node sampling
 Full surgical staging: Laparotomy, peritoneal washings for cytology ± pelvic/para-aortic node sampling
>1c: post-op RadioTx
>2b: radical hysterectomy, ie. remove vagina d/t recurrence risk
>3: RadioTx
4: palliative (EBRT or high dose progesterone for Sx relief)
Most common recurrence site: vaginal cuff. Rx RadioTx ± surgical excsision

ENDOMETRIAL HYPERPLASIA: overgrowth of endometrial cells d/t unopposed oestrogen. Sx: PMB or irregular menstruation.
o Degree (simple or complex): based on glandular:stromal ratio – less stroma in complex
o Atypia: appearance of individual glandular cells (nuclear:cytoplasmic ratio)

46% atypicial hyperplasia have concurrent AdenoCA, or high risk of developing it → Tx: TAH (+BSO if >45y)
No atypia, risk of progression to CA: simple hyperplasia 1%; complex 3.5% → Tx treat cause (eg. unopposed HRT), progestagens
MENORRHAGIA
>80ml blood loss/month or subjectively heavy flow causing disruption to patient.

Si/Sx:
 Flooding
 Anaemia Sx (but may have ↓Hb & feel ok if chronic)
 Clots

Causes:
 Dysfunctional uterine bleeding (DUB) 60%: no identifiable pathology, a/w tubal ligation
 Fibroids
 Polyps
 Endometriosis – a/w dysmenorrhoea
 Endometrial hyperplasia
 ↓progesterone: PCOS, peri-menopause, recent menarche
 Thyroid disorders
 Coagulopathies

Ix:
 Hx & exam (general, bimanual, speculum, VE)
 FBC: Hb, platelets (bleeding disorder). Coag screen only of Hx suggestive
 TFTs
 Day 21 progesterone: if PCOS suspected
Hysteroscopy: intra-cavity
 Beta-hCG: if preg suspected fibroids
 TVUS: assess endometrial thickness, exclude fibroids & polyps
 Endometrial biopsy: rarely <40y
 Hysteroscopy/D+C: inspect uterine cavity, samples to histology

DDx:
 Thyroid dz
 Coag disorders: Von Willibrands, idiopathic thrombocytopenia, anticoag Tx
 Chronic PID
 Endometrial CA
 Copper IUCD

Tx:
1. Medical
o Non-homonal: Mefenamic acid/Ponstan (prostaglandin synthetase inhib), Tranexamic acid (antifibrinolytic)
o Hormonal: COCP, POP, mirena, GnRH analogues (max 6mo)
2. Surgical – if med Tx failed
o Baloon ablation or TCRE – NB must use contraception after (mirena usually placed) as risk of abnormal placentation
o Hysterectomy
o Myomectomy: removal of fibroid in woman whose family not complete
o Polypectomy
3. Other: uterine A. embolization – single/small number of firbroids

Use: measure uterus Saline @ 82degrees

Use: dilate cervix Blunt: EPRC. Sharp: D+C Risks: utterine perf, infxn NB measure uterus w/
Risks: cervical trauma, Risks: infxn, trauma Sound to check it fits
uterine perf, infxn Asherman’s syndrome → Use: endometrial ablation
basal layer trauma & Risks: trauma, infxn, failure
adhesions
AMENORRHOEA
Primary: absence onset menses by 14y w/out 2ndary sex characteristics, or absence onset by 16y in presence of 2ndary sex characteristics
Secondary: absence of menstruation for a time equivalent to at least 3 of the previous cycle intervals, or 6mo of amenorrhea w/hx menst.

Primary Causes
 Pregnancy
 CNS: hypothalamic (stress/exercise/weight-related), Kallman’s syndrome (mutation of short arm of X chromosome, a/w anosmia)
 Anterior pituitary: adenomas, drug-induced hyperprolactinemia, hypothyroidism, empty sella syndrome
 Ovarian: absent germ cells, gonadal agenesis (Turner’s, premature ovarian failure), PCOS
 Outflow tract: mechanical (imperforate hymen), mullerian agenesis, androgen receptor abnormality, androgen insensitivity
 Constitutional delay
Secondary Causes
 Pregnancy
 Ovarian: PCOS, premature ovarian failure
 Hypothalamic: wt loss, exercise, chronis illness, psychological distress, idiopathic
 Pituitary: hyperprolactinemia, Sheehan’s syndrome (postpartum hypopituitarism d/t necrosis a/w hypovolemia/PPH)
 Hypothalamic/pituitary damage: tumours, irradiation, head injury, sarcoid, TB
 Systemic: chronic illness, wt loss, endocrone disorder (thyroid, Cushing’s)

Dx:
 R/O pregnancy
 Hx: 1∘ or 2∘, stress/wt change, acne/hirsutism, headache/visual field defects (pituitary), polyuria/polydipsia, meds
 Exam: wt, BP, thyroid, abdo/pelvic mass, secondary sex characteristics
Ix:
 Urine pregnancy test
 TAUS: assess anatomy of uterus & ovaries
 Hormonal profile:FSH/LH, TFTs, PRL, Testosterone, DHEAS
 CT/MRI of specific indications warrant

Tx: treat underlying cause

 Anovulatory: periodic progesterone to prevent endometrial hyperplasia
 Hypoestrogenic ovulation: induce oestrogen production or give oestrogen to prevent bone loss

Post-pill amenorhhoea: investigate if 6mo since stopping OCP or 12mo since last depo-provera injection
ABDOMINAL MASS
DDx:
 Ovarian CA * *presume until proven otherwise RMI (Risk of Malignancy Index):
 Ovarian cyst Risk of malignancy of an ovarian mass based on
 Large fibroid size, USS findings, CA125, pre/post-menopausal

Ix/Dx: Tx: debulking surgery + combination ChemoTx

 Pelvic USS
 CA125 → Ovarian CA
 CT/MRI

USS features suggestive of CA:

1. Solid/cystic areas
2. Calcifications
3. Bilateral
4. Multilobular
5. Ascites

Tx: TAH + BSO +/- omental & lymph node biopsies

If Pt had 1st degree relative w/ similar dz, what would you suggest?
 BRCA 1 & 2 screen
Overall ~5-10% of cases of ovarian cancer are familial

Mieg’s syndrome: ascites, pleural effusions, benign ovarian tumour (fibroma)

DYSMENORRHOEA/ENDOMETRIOSIS
Dysmenorrhoea: excessive menstrual pain. Affects 30-60% menstruating women.
Primary: idiopathic. Begins at onset of ovulatory cycles, typically within 2y of menarche
Mgmt.: reassurance, NSAIDS, COCP, depo-provera, mirena

Secondary: due to pelvic pathology

o Fibroids
o Adenomyosis: presence of endometrial tissue in myometrium
o Endometriosis
o PID
Mgmt: Hx & exam. If normal exam, trial medical mgmt., if medical fails → diagnostic laparoscopy

Endometriosis: presence of endometrial-like tissue outside the uterus. Affects 7-10% women of reproductive age.
Sites:
 Pelvic – especially uterosacral ligaments
 Extrapelvic : umbilicus, scars, lungs & pleura

Sx:
 Chronic pelvic pain (up to 87%)
 Dysmenorrhoea
 Deep dyspareunia
 Subfertility (38%)
 Ovulation pain
 Cyclical/ perimenstrual symptoms
 Chronic fatigue
 Dyschezia (pain on defecation)

O/E:
 Fixed retroverted uterus
 Pelvic tenderness
 Tender US ligaments
 Enlarged ovaries
 Palpable nodules in pouch of douglas and US ligs

Laparoscopy findings:
 “Powder burn” lesions
 “Gunshot” lesions
 Red implants
 Black- bluish lesions
 Nodules or cysts
 Endometriomas (chocolate cysts)

Mgmt:
1. Medical
 NSAIDS, Progestagens, COCP
 GnRH analogues: Decapeptyl, Zoladex – max 6mo. Risk osteopenia
 Gestrinone: suppresses pituitary gonadatphin release. Inhibits endometrial gowth
 Metoxyprgesterone acetate
 Mirena
2. Surgical ‘kissing ovaries’
 Excision or ablation: 60-70% symptomatic relief. Most effective for deep dz.
 TAH + BSO if failed to respond to med/surg and family complete

DDx chronic pelvic pain:

 Endometriosis
 IBD
 PID
 Adhesions
 Interstitial cystitis
 Musculoskeletal pain
 Nerve entrapment
 Psychological/social
 Pelvic venous congestion
PCOS
6-7% ↑South-Asian

Diagnostic (Rotterdam) criteria - must have 2 or more of:

1. Biochemical/ clinical evidence of hyperandrogenism
2. Ovulatory dysfunction: amenorhhoea/oligomenorrhoea (mensturation at >35d interval)
3. Polycystic ovaries on USS

Multifactorial: familial, excess LH:FSH secretion by pituitary, disordered androgen production/control, peripheral insulin resistance

Hyperandrogenism:
 Hirsutism: male distribution body hair, graded by Ferriman-Gallwey system (<8 normal, >15 mod-severe)
 Acne vulgaris
 Seborrhoea
 Alopecia (male-pattern)

Si: obesity, infertility, hirsutism, acanthosis nigricans, ↑BP

Ix:
 Lab Ix
o ↑FSH:LH (day 3-5) → ratio>3 suggest PCOS (note: both FSH & LH↑ in premature ovarian failure)
o ↑Testosterone/ Free androgen index
o ↑Androstenedione
o ↓Sex-hormone binding globulin
o Serum progesterone (day 21) ↓ - anovulatory cycles
o Random blood glucose ↑
o PRL, TFTs → R/O other causes of oligomenorrhoea
 TVUS: polycystic ovaries → ‘string of pearls’ (12+ peripherally placed follicles w/↑ovarian volume)

DDx:
1. Congenital adrenal hyperplasia
2. Hyperprolactinaemia Virilization:
3. Cushing’s syndrome  Important to differentiate from Hirsuitism
4. Thryoid dysfn  Characterized by
5. Adrenal tumours o Masculinisation
o Severe hirsutism of rapid onset
6. Drugs
o Male pattern balding
7. Idiopathic hirsutism o Deep voice
o Cliteromegaly
Consequences of PCOS  Usually caused by adrenal tumours
 Infertility: 2ndary to anovulation
 Endometrial CA: unopposed oestrogenic stimulation of endometrium
 Metabolic: ↑risk CVD, T2DM, obesity, HTN, sleep apnoea

Mgmt:
 OCP: regulate menstrual irregularities, improbes hirsutism if contains antiandrogen eg. Dianette
 Improve fertility: Clomiphene (ovulation induction), Metformin (improves ovulation + potentiates effects of clomiphene, also
improves insulin resistance), Ovarian drilling (focal destruction of ovarian stroma w/laser or diathermy)
 Improve hirstutism: Wt loss, Anti-androgens eg. spironolactone, OCP containing anti-androgen eg. dianette
 Metabolic: lifestyle modification, Metformin (improves insulin resistance, ↓hyperinsulinemia, ↑fertility)

Effects of PCOS on pregnancy:

o Inaccurate dates
o ↑risk miscarriage, GDM, PET

Long-term sequelae of PCOS:

 T2DM
 Ovarian CA
 CVD (HTN, IHD)
INFERTILITY
Failure to conceive within 12mo of commencing unprotected intercourse. Affects 12% of couples.
Primary: couple never conceived Secondary: at least one previous conception

Causes: roughly 1/3 male factors, 1/3 female, 1/3 mixed.

 Male factors 20%
 Ovarian (anovulation) 20%
 Tubal 30%
 Emdometriosis 10%
 Unexplained 20%

Male factors
Hypothalamic/Pituitary: Testicular dz Genital tract obstruction Defective ejaculation
o Kallmans syndrome o Congenital: Klinefelter’s syndrome 46XXY o Post-vasectomy o Erectile dysfn
o Pituitary dz o Cryptorchidism: failure of testicular descent o Congenital absence o Retrograde
 adenoma o Varicocoele: poor semen quality of vas – a/w CF ejaculation
 Surgery/RadioTx o Infections: mumps orchitis o Infxn: gonorrhea, o Ejaculatory failure
 infarction, sarcoid o Radiation chlamydia, TB
o Anabolic steroids: -‘ve o Drugs: antiandrogens
feedback excess androgen o Smoking
o Obesity o Hyperthermia – NB occupation, clothing
o Anti-sperm Abs

Ovarian
Hypothalamic-pituitary failure: Hypothalamic-pituitary dysfunction: Ovarian failure:
↓FSH, LH Normal FSH, LH ↑ FSH, LH
o Kallmans syndrome o PCOS o Genetic: Turner Syndrome (45XO)
o Wt loss / stress o Premature Ovarian failure
o RadioTx, ChemoTx
o Autoimmune Dz

Tubal
o Infxn: PID: Chlamydia, Gonnorhoea, Pelvic TB
o Surgery → adhesions
o Congential Anomalies

Endometriosis
o Anatomic distortion from pelvic adhesions
o Damage to ovarian tissue by endometrioma formation and removal
o Production of cytokines which impair the normal processes of ovulation, fertilization, and implantation

Unexplained
o Luteal-phase deficiency: Abnormalities of corpus luteum resulting in reduced progesterone levels
o Failure of rupture of the dominant follicle
o Mild endometriosis
o Occult infection
o Immunological causes
o Psychological causes

Ix:
 Hx & exam: male & female
 Male Ix:
o Semen analysis: volume, count, motility, form
o Hormonal profile: FSH, LH, testosterone, PRL, TFT’s
o MAR test: mixed antiglobulin rxn test to detect anti-sperm Abs in semen/blood → Dx >50% abnormally bound sperm, Rx
steroids/IUI
o Post-coital test
o Karyotype
 Female Ix:
o Rubella, smear
o Hormonal analysis:
 Ovarian control: FSH, LH, E2 (d3-5)
 Ovulation: progesterone (day 21 / 7d before period)
 Endocrine: TFT’s, PRL, testosterone → if indicated
o Tubal patency:
 Hysterosalpingogrpahy (radio-opaque dye +xray)
 Lap+dye: ?endometriosis, Hx PID or pelvic surgery
 Hysterosalpingocontrastsonography (HyCoSy) (USS+hydrotubation)
o Other: TVUS, hysteroscopy, progesterone challenge test
Tx: as per cause
 General advice: smoking, C2H5OH, wt loss, temperature
 Assisted conception: ICSI, IUI, IVF, ovum donation
ASSISTED CONCEPTION

Intrauterine Insemination (IUI)

Introduction of selected sperm (highly motile) into uterine cavity via plastic catheter
 Unstimulated: urine/serum LH levels monitored - inseminate at LH surge
 Stimulated: ultrasound monitoring, when one follicle is > 17mm hCG is given to trigger ovulation and insemination is performed 24-
48 hrs later

Indications:
 Unexplained Infertility
 Mild male factor infertility
 Coital or ejaculatory disorders
 Donor insemination

In Vitro Fertilization (IVF)

Sperm & oocyte fertilized in-vitro, resulting embros transferred to uterine cavity

Indications:
 Unexplained Infertility
 Severe Endometriosis
 Failed Ovulation Induction
 Tubal disease
 Cervical factor
 Male factor (ICSI required- direct injection of single sperm directly into cytoplasm of oocyte)
 Egg donation

Technique:
1. Ovarian stimulation: GnRH analogue/antagonist to downregulate pituitary. Rx FSH for follicular recruitment + development. hCG
triggers oocyte maturation
2. Oocyte retrieval: US guided needle aspirate of follicles containing oocytes
3. Insemination: IVF/ICSI. Fertilization assessed after 16-18h, embryos incubated for 2-5d
4. Embryo transfer: 1-2 embryos (3 if >40y) transferred to uterine cavity through soft plastic catheter
5. Luteal phase support: progesterone transvaginally/IM or hCG for 15d

Factors affecting success: female age (↓>35), duration of infertility, Hx unsuccessful Tx, previous pregnancies, sperm quality

Risks of assisted reproduction

 Multiple pregnancy
 Ovarian hyperstimulation syndrome (OHSS)

OHSS:
Potentially life threatening effect of ovulation induction. Occurs mainly with use of gonadotrophins in lean PCOS patients.
Cardinal Si: ↑ follcile numbers & ↑ oestadiol levels
Complicates 4% of ovulation induction cycles, severe requiring admission in < 1%

Pathology: ↑vascular permeability → fluid shift from intravascular to extravascular space. Triggered by hCG administration

Sx: abdo pain, bloating, N+V, resp distress

Si: enlarged uterus, ascites, pleural effusion, oliguria/anuria, ↑Hct, ↑WCC, electrolyte disturbances

Grading: mild, moderate, severe

Risks:
 Renal failure
 VTE
 ARDS
 Death

Mgmt:
 Prevention: USS monitoring ovulation induction, discontinue if estradiol levels ↑↑ or ↑↑follicles, no hCG admin, freeze embryos
 Tx: supportive (analgesia, anti-emetics), monitor fluid balance, thromboprophylaxis, abdo paracentesis
VE / CERVICAL SMEAR / BIMANUAL
Procedure:
 Introduce self + ensure chaperone present
 Consent pt
 Wash hands & put on gloves
 Observation (external examination), part labia: “vulva, vagina, & perineum appear normal”
o Lesions
o Scars
o Discoloration
o Discharge
Use: Visualize cervix
o Cysts Risks: cervical/vaginal trauma,
 Lubricate speculum, insert & open it (close twisty cap) infxn
 Inspect the cervix: normal nulliparous/multiparous?
 Insert cytobrush (rotate 360degrees 3-5 times)
 Dip the brush into the bottle, label bottle
 Unlock speculum and remove it

VE
 Consent pt
 Gloves and lubricant
 Inserts fingers
o Feel cervix and uterus: Uterus anteverted? Size? Smooth? Mobile?
o Feel the adnexa: Mass? Tenderness?

Questions
Iliac fossa mass:
1. Ovarian cyst or carcinoma
2. Endometrioma
3. Appendicular mass/abscess
4. Fibroids

Causes of abdo/pelvic pain:

 Ovarian carcinoma/cysts
 Fibroids
 Ectopic pregnancy
 Pelvic abscess
 Endometriosis
 UTI/pyelonephritis
 Adhesions (appendicular abscess/mass) –right
 Impacted fecal matter (left)

Causes of enlarged uterus:

1. Large fibroids
2. Pregnancy
3. Malignancy
4. Adenomyosis

Clinical findings w/ suspected malignancy

o Cervical motion tenderness (cervical excitation- move the cervix and the patient feels the pain)
o Tenderness in RIF/LIF
o Abdo tenderness

National cervical screening:

 25-44y: every 3 years
 45-60: every 5 years

CIN RFs
1. HPV
2. Smoking
3. Multiple sexual partners
4. Immunosupression

LLETZ Risks:
o Bleeding in pregnancy
o Cervical incompetence
o Miscarriage
Bimanual and speculum examination
1. Introduce self
2. Verbal consent from patient
3. Ideally, I would have a chaperone with me
4. Ideally the patient should be exposed from the xyphoid process to mid-thigh.
5. Sterilise hands
6. Gloves

In real life, smear should be performed before examination as exam removes the cells from the
cervix.
 Cusco’s speculum- disposable plastic speculum.
 Metallic speculum might be used
 Cytobrush- must be inserted into the cervical os.
o Rotate 3-5 times clockwise.
 Dip into the solution.
 Make sure that it is labeled correctly! Sometimes they try to catch students out here!
 Speculum always inserted sideways before being rotated.
 Must be locked!

Bimanual examination:
 On inspection, I cannot see any scars or abnormal marks, and the perineum looks normal.
 I will lubricate my fingers on right hand.
 Part labia with two fingers of left hand.
 Insert two fingers of right hand
 Use left hand to stabilize the uterus with your left hand (there may be a mass on the model, but usually not).
 Feel the cervix- finger will not go in in nulliparous women, but might be inserted in multiparous women (not on model!).
 The uterus will feel like a pear.
 Comment that you can feel the uterus and cervix and if it is normal size- if they ask what is normal size say it feels about pear sized.
 It is anteverted- tilted forward. 4/5 uteruses are anteverted, 1/5 are retroverted.
 It is mobile- I can move it from side to side.
 It is smooth and firm to touch. Must mention these five things!
 Move fingers to right adnexa and move left hand to right also. Same for left. Put hands into right and left iliac fossae- not the kidneys!
 Move to the posterior fornix- feel for pouch of Douglas.
 Take off gloves, thank patient.

Typical questions for bimanual exam and smear station:

DDX for mass in abdo:
 Fibroids
 Endometrial ca
 Ovarian cyst or malignancy
 Endometrioma
 Pelvic abscess or mass
 Specifically on right side- appendicular mass.
 Left side- loaded rectum in severe constipation.
 Pregnancy
 Ectopic pregnancy
Causes of lower abdo pain/R/LIF pain:
 Ovarian cyst
 Torsion or rupture of ovarian cyst
 Pelvic abscess
 UTI
 Endometriosis
 PID
 Ectopic pregnancy
Smear test- what is the age?
 National cervical screening programme-
o 25-44 every 3 years
o 45-65 every 5 years
What is the most common cause of abnormal smear?
 HPV 16 & 18
A patient has LLETZ- what are the complications?
 Increased risk of first and second trimester miscarriage
 Abnormal PV bleeding (as the endocervix is exposed and is more fragile than the exocervix).
 Preterm labour and preterm delivery- due to shortened cervix that is incompetent at holding the pregnancy.
 Gynae instruments station:
Instrument Description Indication Complications Picture
Laparoscope A thin lighted Diagnostic Infection, bowel perforation,
tube that is indication: bowel injury.
passed through unexplained pelvic
an incision in the pain, subfertility,
abdomen. May be adnexal masses,
used for staging of
diagnostic or endometriosis,
therapeutic ectopic pregnancy.
procedures. Therapeutic
indications:
Advantages of sterilization,
laparoscopy over adhesiolysis,
laparotomy? treatment of
Cost-effective, endometriosis,
reduced hospital ovarian cystectomy
stay, reduced risk (benign lesions),
of complications, ectopic pregnancy,
early BSO, TLH and LAVH,
mobilization myomectomy, tubal
post-surgery. surgery.
Varres needle A spring-loaded Used to create Infection, pre-peritoneal
needle. pneumoperitoneum insufflation of gas resulting in
for laparoscopic surgical emphysema, injury
surgery. to bowel, bladder or major
blood vessels (aorta).

Trochar and The trocar functions May not be able to penetrate

Cannula as the portal for the through the incision.
subsequent
placement of other
instruments (e.g.
scissors, graspers,
staplers).

Hysteroscope A thin, lighted Unexplained uterine Infection, uterine perforation,

tube that is bleeding, post- bladder injury, bleeding,
inserted into the menopausal anaesthesia complications.
vagina to bleeding, infertility,
examine the intrauterine
cervix and inside adhesions, polyps
of the uterus. and fibroids
investigation,
NB- do not sterilization,
introduce any proximal tubal
instrument into obstruction.
the uterine cavity
before
hysteroscope (e.g.
uterine sound)
because it may
cause bleeding
and obscure the
view and cause
you to miss NB
pathology.
Uterine Sound Metal probe Used for probing the Bleeding, uterine perforation,
uterus through the infection, cervical
Several different cervix. They can be incompetence.
sizes. used to measure the
length of the cervical NOT to be used in pregnancy!
Similar to Hegar canal and uterus
cervical dilators. (<10cm is normal),
to determine the
level of cervical
dilation or to dilate
the cervix further.
Sponge They are used to Cervical trauma if used
holding hold sponges for inappropriately for this
forceps cleaning the abdo purpose.
down prior to
surgery- but also
often used in gynae
surgery to hold the
anterior lip of the
cervix.

Vulsellum’s More traumatic Used to hold the Cervical trauma

Forceps than sponge- anterior lip of the
holding forceps. cervix for Do NOT hold the pregnant
hysterectomy or cervix with this.
pelvic floor repair.

Tooth (pick- More traumatic Used for holding Trauma

up) Forceps than Vulsellum’s sturdy structures
such as skin, rectus
sheath, fascia.

Sim’s An instrument Taking a pap smear, Vaginal laceration, urethral

Speculum/ that is inserted inspecting the cervix damage, patient discomfort.
Cusco’s into the vagina so for
speculum that proper vision bleeding/irritation/
can be attained ca, visualizing
Cusco’s and the fistulae, prolapse,
speculum is procedure can be endometrial biopsy.
self-retaining performed
in the vagina. easily. Bivalved-
two blades.

Rotunda Metal catheter Used to empty the

Catheter that is wavy- bladder.
looking
Allis Clamp A surgical Used to grasp fascia Causes trauma, so usually
instrument with and soft tissues such used on tissue to be removed.
sharp teeth, used as breast or bowel
to hold or grasp tissue. Vaginal
heavy tissue. hysterectomy or
anterior/posterior
vaginal repair.

Currette A metal rod with Used for scraping Dilation & curettage of the
a small scoop or or debriding biologic uterus-
hook at the head. al tissue or debris in Diagnostic: abnormal uterine
a biopsy, excision, or bleeding, evaluation of
cleaning procedure. intrauterine findings on
imaging, alternative to
endometrial biopsy,
endometrial sampling.
Therapeutic: ERPC, uterine
haemorrhage, gestational
trophoblastic disease,
abortion (uncommon
method).
Delayed menstruation:
Primary amenorrhoea

 Causes:
o Constitutional (family members all had late menarche)
Stress
Athletic girls (hypogonadorophic)
Anorexia nervosa
 History:
o Ask patient about other signs of sexual characteristics, pubic hair, breast development
o Is patient sexually active
o Is patient taking meds for any illness
o Outrule macroprolactinoma ask a few symptoms (headache, vertigo, visual disturbance(bitemporal hemianopia)
 Pathological causes:
o Endocrine  hyperthyroidism, PCOD, pituitary disorders, hyperprolactinoma
o Congenital  Marfans syndrome, Turners syndrome, testicular feminization syndrome
o Imperforate hymen
o IBD
o Cystic fibrosis
 Investigations:
o FSH, LH, testosterone, TFT’s, progesterone and prolactin
o Karyotype
Post-menopausal Bleeding:
PV bleeding that occurs 12 months post cessation of periods.

 Average age of menopause is 51.

 Very serious- think of endometrial ca. The primary goal of investigation will be to exclude malignancy!
 Causes:
o Atrophic vaginitis- atrophy of the vagina (most common cause)- treat with local oestrogen.
o Endometrial hyperplasia
o Endometrial ca (10%)
o Polyps (cervical)
o Cervical ca
o HRT
o Trauma
o Medication- blood thinner
o Fibroid only in early menopausal years

*In the uterus, the collapsed, atrophic endometrial surfaces contain little or no fluid to prevent intracavitary friction. This results in microerosions
of the surface epithelium and a subsequent chronic inflammatory reaction (chronic endometritis), which is prone to light bleeding or spotting.

History:
 Take a thorough history, excluding RF of endometrial ca.
o ESP Tamoxifen- selective oestrogen agonist in endometrium.
o Hyperoestrogenic state- obesity, T2DM, PCOS.
o Breast CA- lifestyle RF
o HRT
o HTN
 What is the nature of the bleeding (temporal pattern, duration, postcoital, quantity)?
 Is there a family history of breast, colon, and endometrial cancer?
 Medications?

Investigations:
 Investigations same as for endometrial ca.
o Must perform endometrial assessment- TVUS to check endometrial thickness, or via pipelle biopsy (OPD not very
sensitive- biopsies on 6% of the endometrium) or book for hysteroscopy/D&C.
Male infertility:
You may be required to read a semenalysis.

Causes:
 Congenital
o Kallmann’s syndrome
o Kleinfelter syndrome
o Cryptorchidism
 Acquired
o Anabolic steroids
o Varicocoele
o Infxn (e.g. Mumps)
o Drugs- e.g. immunosuppressive
o Smoking
o Excessive alcoholism
o Environmental toxins- occupational is NB, e.g. if he works in very high temp.

Report:
 Sperm count: >15-20million is normal
 Volume: >1.5mls
 Motility: 40-50% or more
 Normal morphology: 4% or more
 Abnormal morphology: 96% (this is correct!) or less

30% of infertility is due to male factors, 40-60% is female, 25% is unexplained.

How to collect the semen:

 Avoid intercourse for at least 3 days before providing a specimen
 Specimen should be brought to the hosp within 3 hours and kept warm.

Investigations:
 Karyotype
 Hormonal profile- FSH, LH, testosterone, prolactin.
 MAR test- mixed antiglobulin reaction test: this is performed to detect anti-sperm antibodies.
o Treatment for this- immunoglobulins. This improves the sperm count.
 If these do not show infertility- test the woman’s cervical mucous.

Treatments:
 In utero insemination (before IVF)
 ART
 ICSI- intra cytoplasmic sperm insemination.

Advice:
 Smoking cessation
 Obesity advice
 Reduce alcohol intake
 Healthy lifestyle
 Exercise
Fibroids:
A uterine fibroid is a leiomyoma that originates from the smooth muscle layer
(myometrium).

Types:
 Submucosal
 Myometrial
 Subserosal- in the outer visceral peritoneum of the uterus. Usually
pedunculated.

Symptoms:
 Lower abdo discomfort
 Increased urinary frequency
 Heavy +/- irregular periods
 Asymptomatic
 Usually do not cause dyspareunia as they are mobile
 Palpable mass only when very large

Complications:
 Infertility
 Recurrent miscarriage (esp if they are large)
 Preterm labour
 Malpresentation if fibroid is in lower uterine segment.
 Increased risk of caesarian
 Degeneration of the fibroid in pregnancy

Management:
 NSAIDs, mefanemic acid, transexamic acid
 COCP
 GnRH analog
 Myomectomy surgery- laparoscopy or laparotomy or transcervical if the fibroids are submucosal.
o Complications: bleeding, injury to bowel, bladder and ureter, wound infection, UTI, VTE, PE, infertility, incomplete
resection, uterine perforation.
 Hysterectomy if troublesome and family complete.
 Selective uterine artery embolization.