1 Task Diagnostic methods . Anatomy of female reproductive system.

Describe the innervations of uterus and ovaries

Describe the ligaments of uterus

What gynecological diseases may be diagnosed by laparoscopy?

1.Describe the innervations of uterus and ovaries

Uterus innervation

The nerve supply of the uterus is derived principally from the sympathetic system and partly
from the parasympathetic system. Sympathetic components are from T5 and T6 (motor) and
T10 to L1spinal segments (sensory). The somatic distribution of uterine pain is that area of the
abdomen supplied by T10 to L8. The parasympathetic system is represented on either side by
the pelvic nerve which consists of both motor and sensory fibers from S2, S3, S4 and ends in
the ganglia of Frankenhauser.

Ovaries innervation

Sympathetic supply comes down along the ovarian artery from T10 segment. Ovaries are
sensitive to manual squeezing.

2.Describe the ligaments of uterus

The uterus contains three suspensory ligaments that help stabilize the position of the uterus
and limits its range of movement. The uterosacral ligaments keep the body from moving
inferiorly and anteriorly. The round ligaments restrict posterior movement of the uterus. The
cardinal ligaments also prevent the inferior movement of the uterus.

3.What gynecological diseases may be diagnosed by laparoscopy?

ovarian cysts or tumours

ectopic pregnancy
pelvic abscess, or pus
pelvic adhesions, or painful scar tissue
endometriosis
uterine fibriods
pelvic inflammatory disease
reproductive cancers

Task Diagnostic methods . Anatomy of female reproductive system.

What is the function of the ovaries?

What gynecological diseases may be diagnosed by hysteroscopy?

What gynecological diseases may be diagnosed by US?

1.What is the function of the ovaries?

These organs are responsible for the production of the egg cells (ova) and the secretion of
hormones. Such as progesterone ,estrogen. The process by which the egg cell (ovum) is
released is called ovulation. The speed of ovulation is periodic and impacts directly to the
length of a menstrual cycle

2.What gynecological diseases may be diagnosed by hysteroscopy?

diagnose conditions – such as fibroids and polyps (non-cancerous growths in the womb),
adhesions, abdominal bleeding.

3.What gynecological diseases may be diagnosed by US?

ectopic pregnancy
pelvic abscess, or pus
pelvic adhesions, or painful scar tissue
infertility

endomatriosis
uterine fibroids
ovarian cysts and tumors

pelvic inflammatory disease

reproductive cancers

Case 2 Pelvic Inflammatory Disease (PID)

 The young woman (has never given a birth) got acutely sick on the second day after
the medical abortion. Complaints: indisposition, fever 39º C, paroxysms of chills. The
patient took a pill of aspirin, called the ambulance and was hospitalized. During the
examination tachycardia, pale skin, increasing of leukocytes (10,0 g/l) and ESR 35
mm/h were marked. Normal size of the abdomen, soft, moderate pain in the area of
womb. The bimanual examination determined the increased size of womb, soft
consistence, mobile and moderate painful, the uterus os is closed. Vaginal discharge,
bloody, with bad smell.
1.Make the diagnosis
2.Specify your tactics
3. What complication is patient having after the medical abortion?

.1 .Make the diagnosis

endometritis due to an infection of the pelvic inflammatory disease

2.Specify your tactics

Outpatient Treatment

Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or

Ceftriaxone, 250 mg intramuscularly, or

Equivalent cephalosporin

Plus:

Doxycycline, 100 mg orally 2 times daily for 14 days

With or without:

Metronidazole, 500 mg orally 2 times daily for 14 days

Criteria for hospitalization:

Suspected pelvic or tubo-ovarian abscess

Pregnancy

T above 38
Inability to tolerate PO intake

Peritoneal sings

Failure to respond to oral antibiotics within 48 hrs

Active management by laparoscopical repeated drainage

· And also we can give pain relievers such as narcotic analgesics,opiods and NSAID.

· Rest is advised for those with severe disease

· Intravenous therapy is recommended for patients with more severe clinical disease.
Like this patient temperature is more than 38 c.

· Patient should be advised to avoid unprotected intercourse

3. What complication is patient having after the medical abortion?

· Ectopic pregnancy. PID is a major cause of tubal (ectopic) pregnancy. In an ectopic

pregnancy, the fertilized egg can't make its way through the fallopian tube to implant in the
uterus. Ectopic pregnancies can cause massive, life-threatening bleeding and require
emergency surgery.

· Infertility. PID may damage your reproductive organs and cause infertility — the
inability to become pregnant. The more times you've had PID, the greater your risk of
infertility. Delaying treatment for PID also dramatically increases your risk of infertility.

· Chronic pelvic pain. Pelvic inflammatory disease can cause pelvic pain that may last
for months or years. Scarring in your fallopian tubes and other pelvic organs can cause pain
during intercourse and ovulation.

· And also, there can be severe and prolong bleeding.

· fever

· Infections leads to several complications such as peritonitis, abscess formation, blisters,

endometritis etc.

· Gastrointestinal discomfort
A 23-year-old patient was delivered to the emergency room by the ambulance team with
complaints of sharp pains in the lower abdomen, nausea, purulent bloody discharge from the
genital tract, and frequent urination. She fell ill acutely during the menstruation. A woman
is not married. Upon receipt, a moderate condition. Body temperature 39 ° C, blood
pressure 110/70 mm Hg, pulse 110 beats per 1 minute, hemoglobin 110 g / l, white blood cell
count 12.0 G / l. The abdomen is moderately swollen, there is tension in the muscles of the
anterior abdominal wall, a positive symptom of Shchetkin-Blumberg in the lower sections.

Status genitalis: in a bimanual examination, the uterus and its appendages cannot be
determined due to the sharp pain and tension of the abdominal muscles. The cervical canal
is closed, purulent white with an admixture of blood.

1. Make the diagnosis

2. Specify your tactics

3. Prognosis

1.Make the diagnosis

pelvic peritonitis due to Salphingitis

2.Specify your tactics

1. Treatment is using antibiotics and should be initiated quickly. Because it can be due to
an infection, the treatment consists of antibiotics administration. The doctor may suggest to
the patient, before the antibiogram results (test used to determine germ sensitivity to certain
antibiotics) , to use broad-spectrum antibiotics(such as
Doxycycline,Minocycline,Aminoglycosides (except for
streptomycin,Ampicillin,Amoxicillin/clavulanic acid (Augmentin),Azithromycin.

2. narcotic analgesics,opiods and NSAID.

3. If the infection has caused an abscess, your doctor may perform laparoscopic surgery to
drain it.

4. Rest

5. Intravenous therapy is recommended for patients with more severe clinical disease.
Like this patient temperature is more than 38 c.

6. Patient should be advised to avoid unprotected intercourse.

3.Prognosis

It Is bad.

complications such as

· pelvic thrombophlebitis,

· formation of pelvic abscess,

· ectopic pregnancy,

· chronic infection,

· sepsis.

Case 3 Common Sexually Transmitted Diseases (STDs)

A 20-year-old woman presents to her gynecologist’s office complaining of several days of

vaginal itching and increased vaginal secretions that have an unpleasant odor. She denies any
recent fever, back pain, hematuria, or vaginal bleeding. She has been sexually active with
multiple sexual partners and rarely uses protection. On examination she has a moderate
amount of frothy green discharge. Amine “whiff” test of the discharge is negative, and the
pH of the discharge is 6. Multiflagellated organisms are seen on microscopy.
What is the most likely diagnosis in this patient?
Prescribe possible treatment

1.What is the most likely diagnosis in this patient?

 Trichomoniasis vaginalis

2.Prescribe possible treatment

· Get comfortable with obtaining a thorough sexual history

· Check oral cavity if genital STD suspected

· Metronidazole or in single oral dose of 2g or 400mg twice daily

· Tinidazole single oral dose 0f 2g.

· Don’t drink any alcohol for the first 24 hours after taking metronidazole or the first 72
hours after taking tinidazole. It can cause severe nausea and vomiting.

· Both partners should be treated.

· Both should be screened for other’s STDs.

· Minimum of annual screening for STDs is recommended, with more frequent

screening if high risk behaviors are reported

· Partner notification and risk reduction counseling for both patient and partner is an
important part of treatment and follow-up.
· The following factors can influence a woman’s understanding of STDs and need for
screening:

· Language and literacy level

· Cultural and social background and its impact on her

· understanding of health, illness, and the female anatomy

· Comfort with discussing sexual health issues

· Comfort and previous experience with STD screening or testing

· History of sexual abuse and/or domestic violence may cause anxiety and exam refusal

STD task

A 29-year-old woman went to the doctor of the antenatal clinic with complaints of abundant
vaginal discharge with a smell, vulvar itching. Considers herself ill for a week. Was casual
sexual intercourse. It is not protected from pregnancy.

A gynecological examination revealed edematous hyperemic mucous membrane of the

vagina, profuse pus-like foamy discharge with an unpleasant odor. The cervix is edematous
hyperemic with pus discharge from the cervical canal. The uterus and appendages are not
changed, painless on palpation. Vaults, parametries are free.

In the native smear from the vagina, mobile trichomonads were found.
 1. Formulate a preliminary diagnosis.

2. Is the examination sufficient? If not, then suggest a plan for further examination.

3. Suggest a patient treatment regimen.

1. Formulate a preliminary diagnosis.

Diagnosis- Trichomoniasis vaginalis

· During A gynecological examination revealed edematous hyperemic mucous

membrane of the vagina, profuse pus-like foamy discharge with an unpleasant odor. The
cervix is edematous hyperemic with pus discharge from the cervical canal distinguish
strawberry cervix with punctuate hemorrhage. The uterus and appendages are not changed,
painless on palpation. That is mean by this infection does not ascend to the upper genital
track.so it not leads to any pelvic inflammatory disease. And also the Vaults, parametries are
free.

2. Is the examination sufficient? If not, then suggest a plan for further examination.

· The examination is not sufficient. Because Neisseria gonorrhea and chlamydia

trachmatis can be seen on the same sample.

· By using subjective examination, asking patient about the sexual history and also by
using objective examination we can ask from the patient about vaginal discharge.

· And also we can do the pelvic examination and uterus examination for further
diagnosis.
· Instrumental examination

· After the Diagnosis confirmed by microscopy ,

· So we can do a culture for further diagnosis. For the culture medium we can use
finnberg-whittngton medium and diamond’s medium.

· We can do Other FDA approved tests: such as

· OSOM Trichomonas Rapid Test

· Affirm VP III

· NAAT(nucleic acid amplification test) preferably on a vaginal or endocervical swab or

on urine.,with sitivities and specificities reaching over 95% , depending on the specimen and
the test. Some NAATs also detect Neisseria gonorrhoea and chlamydia trachmatis on the
same sample: for these the optimal test is a vulvovaginal swab.

· Microscopy and culture of a sample of the vaginal discharge and POCT using different
techniques are also used but are limited by reduced sensitivity.

3. Suggest a patient treatment regimen.

· Get comfortable with obtaining a thorough sexual history

· Check oral cavity if genital STD suspected

· Metronidazole or in single oral dose of 2g or 400mg twice daily

· Tinidazole single oral dose 0f 2g.

· Don’t drink any alcohol for the first 24 hours after taking metronidazole or the first 72
hours after taking tinidazole. It can cause severe nausea and vomiting.

· Both partners should be treated.

· Both should be screened for other’s STDs.

· Minimum of annual screening for STDs is recommended, with more frequent

screening if high risk behaviors are reported

· Partner notification and risk reduction counseling for both patient and partner is an
important part of treatment and follow-up.

· The following factors can influence a woman’s understanding of STDs and need for
screening:

· Language and literacy level

· Cultural and social background and its impact on her

· understanding of health, illness, and the female anatomy

· Comfort with discussing sexual health issues

· Comfort and previous experience with STD screening or testing

· History of sexual abuse and/or domestic violence may cause anxiety and exam refusal

Case 4 Regulation of normal menstrual cycle. Abnormal menstrual cycle

The woman, 34 years old, has the following complaints: headaches, amenorrhea and
she gains weight. BP 90/60. She hasn’t recently taken any of pills. The results of diagnostic
are:
- Prolactin 155 ng/ml (N. 2-25)
- T4 – 1,8 mkg/dcl (N. 4,5-12)
- T3 – 85 ng/dcl (N. 90-200)
- TTG – more than 40 I/ml (N. 0,1-4,5)
- Pituitary is enlarged.
Answer the following questions:
1. What is the most certain diagnose?
a) Hyperprolactinemia-amenorrhea in case of prolactinoma
of pituitary.
b) Adenoma of pituitary
c) Hyperprolactinemia after taking phenothiazines
d) Hyperprolactinemia-amenorrhea in case of primary
hypothyroidism
2. The drugs for therapy of hyperprolactinemia are, except:
a) Parlodel
b) Bromocriptine
c) Dostinex
d) Imipraminum

1.What is the most certain diagnose?

hyperprolactinemia – amenorrhea in case of primary hypothyroidism.

2.drugs for therapy of hyperprolactinemia are, except:

-d imipraminum

Case 4.2 Regulation of normal menstrual cycle. Abnormal menstrual cycle

A girl of 14 years turned to the gynecological hospital on duty complaining of profuse uterine
bleeding. From the anamnesis it was found that the patient has profuse, with clots, irregular
menstruation after 6-8 weeks for 8-10 days, painless during the year. Suffers from nosebleeds
from an early childhood. Menarche is 13 years old.

On examination: the skin is pale, pulse 82 beats per 1 minute, rhythmic, blood pressure
110/70 mm Hg, hemoglobin 90 g / L. The abdomen is soft, painless.

Status genitalis: the external genitalia are developed correctly, female-type body hair, the
hymen are intact. Per rectum: uterus of normal size, painless; uterine appendages on both
sides are not enlarged. Discharges from the genital tract are bloody, plentiful.

1. Make a preliminary diagnosis

2. Assign laboratory examination methods

3. Perform an instrumental examination (if necessary)

4. Prescribe treatment

1. Make a preliminary diagnosis

Diagnosis is menorrhagia.

2. Assign laboratory examination methods

Full blood count . Anemia can be detected. Decreased platelet levels.

Coagulation profile can be taken

Hormonal profile testing which includes menstrual hormones and thyroid function tests.
 3. Perform an instrumental examination (if necessary)

Ultrasound scan

Biopsy

4. Prescribe treatment

NSAID can be giving to reduce blood loss. Mefenemic acid 500mg.

Tranexemic acid as a fibrinolytics agent.

Combined oral contraceptives.

Case 5.1 Abnormal Uterine Bleeding

Patient of 32 years old, addressed the doctor in the maternity welfare centre having
complaints concerning dark bloody allocations from the genital tract right prior to the
menses.
Vaginal examination: the cervix is of cylindrical shape, it is not deformed, nodous,
fine cystic formations of purplish blue color are defined. The uterus is of spherical shape, it is
larger than normal, painless at the palpation. Ovaries are not enlarged, are painless.
1. Make preliminary diagnosis.
2. Is it necessary to make the examination after the menses ?
3. What are the most reliable modern methods of inspection?
4. Suggest the treatment

. Make preliminary diagnosis.

Cervical polyp- cervical cancer I think

2. Is it necessary to make the examination after the menses ?

Yes, to exclude other pathologies such as cervical cancer, polycystic syndrome,

endometriosis etc

3.What are the most reliable modern methods of inspection?

· Routine pelvic exam.

Instrumental examination
· Bimanual pelvic palpation of the uterus- by palpating we can sense the finger like
structure and alos it is painless. The patient does not feel any pain.

· Transvaginal ultrasound.

hysterosonography

Laboratory examination

· Hysteroscopy.

· Endometrial biopsy.

4.Suggest the treatment

· Sometimes, cervical polyps will disconnect from the cervix on their own. This can
occur while a woman is menstruating or during sexual intercourse.

· Surgical treatment- Doctors don’t routinely remove cervical polyps unless they cause
symptoms. Removing cervical polyps is a simple procedure that your doctor can perform in
their office. No pain medication is necessary.

Methods for removing cervical polyps include:

twisting the polyp off at the base
tying surgical string around the base of the polyp and cutting it away
using ring forceps to remove the polyp

Methods to destroy the base of the polyp include the use of:
liquid nitrogen
electrocautery ablation
laser surgery

Case 5.2 Abnormal Uterine Bleeding

The Woman, 45 years old, came to the Consultation for prophylactic investigation
without any complaints. She was pregnant 4 times - had 3 deliveries and 1 abortion. During
colposcopy doctor saw the "cauliflower" growths on the cervix of the uterus and saw drop
hemorrhage after touching this growths.

1. What is your diagnosis?

2. Which methods of investigation should be used at this case?

3. Explain the medicine tactic.

What is your diagnosis?

Squamous cell carcinoma of the cervix of the uterus

2.Which methods of investigation should be used at this case?

The following tests may be used to diagnose cervical cancer:

Laboratory investigations

· Biopsy.

· Pap test.

o The liquid-based cytology test,

· HPV typing test.

· Colposcopy.

Instrumental examination

· Bimanual pelvic examination.

· X-ray.

· Computed tomography (CT or CAT) scan.

· Magnetic resonance imaging (MRI).

· Positron emission tomography (PET) or PET-CT scan.

If there signs or symptoms of bladder or rectal problems, these procedures may be

recommended:

· Cystoscopy.

· Sigmoidoscopy

3.Explain the medicine tactic.

Treatment for cervical cancer depends on how far the cancer has spread.

Cone biopsy

Surgery

Trachelectomy

Hysterectomy

Pelvic exenteration

Radiotherapy

Chemotherapy

Case 6 Hirsutism in women

Patient M., 34 years old, addressed to the doctor of maternity welfare center having
complaints of the infertility,disruption of menstrual function and excessive grouth of hairs on
the back, abdomen and mammary glands. Menses since the age of 18, cycles are of irregular
character so far, with delays up to 3-4 months. According to ultrasonography data, the
ovaries are of increased size, up to 4.5х3х3.5 centimeters, the structure polycystic, cortical
layer thickened.
1. Make the diagnosis.
2. What is the required medical inspection in the maternity welfare center.
3. Possible methods of diagnostics in the hospital.
4. Treatment.
5. Prognosis for pregnancy.

1.Make the diagnosis.

· Hirsutism leads to polysystic ovarian syndrome

2.What is the required medical inspection in the maternity welfare center.

· No single test can diagnose PCOS. doctor will start by asking about your symptoms
and medical history and by doing a physical exam, and possibly a pelvic exam.

· They might give you blood tests to measure your hormone levels, blood sugar, and
cholesterol. An ultrasound can check your ovaries for cysts, look for tumors, and measure the
lining of your uterus.

3.Possible methods of diagnostics in the hospital.

Doctors typically diagnose PCOS in women who have at least two of these three symptom.

· high androgen levels

· irregular menstrual cycles

· cysts in the ovaries

doctor should also ask whether you’ve had symptoms like acne, face and body hair growth,
and weight gain.

· Physical exam. Your doctor will measure your blood pressure, body mass index (BMI),
and waist size. They will also look at your skin for extra hair on your face, chest or back,
acne, or skin discoloration. Your doctor may look for any hair loss or signs of other health
conditions (such as an enlarged thyroid gland).

· pelvic exam. can look for any problems with your ovaries or other parts of your
reproductive tract. During this test, your doctor inserts gloved fingers into your vagina and
checks for any growths in your ovaries or uterus.

· Blood tests check for higher-than-normal levels of male hormones. You might also
have blood tests to check your cholesterol, insulin, and triglyceride levels to evaluate your
risk for related conditions like heart disease and diabetes.

· An ultrasound uses sound waves to look for abnormal follicles and other problems
with your ovaries and uterus.

There is no single test to diagnose PCOS. To help diagnose PCOS and rule out other causes
of your symptoms, your doctor may talk to you about your medical history and do a physical
exam and different tests:

4.Treatment.

diabetes drug metformin (Glucophage) to lower insulin resistance, regulate ovulation, and
help with weight loss.
PCOS treatment focuses on managing your individual concerns, such as infertility, hirsutism,
acne or obesity. Specific treatment might involve lifestyle changes or medication.

Lifestyle changes

Your doctor may recommend weight loss through a low-calorie diet combined with
moderate exercise activities. Even a modest reduction in your weight — for example, losing 5
percent of your body weight — might improve your condition. Losing weight may also
increase the effectiveness of medications your doctor recommends for PCOS, and can help
with infertility.

Medications

To regulate your menstrual cycle, your doctor might recommend:

· Combination birth control pills. Pills that contain estrogen and progestin decrease
androgen production and regulate estrogen. Regulating your hormones can lower your risk
of endometrial cancer and correct abnormal bleeding, excess hair growth and acne. Instead
of pills, you might use a skin patch or vaginal ring that contains a combination of estrogen
and progestin.

· Progestin therapy. Taking progestin for 10 to 14 days every one to two months can
regulate your periods and protect against endometrial cancer. Progestin therapy doesn't
improve androgen levels and won't prevent pregnancy. The progestin-only minipill or
progestin-containing intrauterine device is a better choice if you also wish to avoid
pregnancy.

To help you ovulate, your doctor might recommend:

· Clomiphene. This oral anti-estrogen medication is taken during the first part of your
menstrual cycle.
· Letrozole (Femara). This breast cancer treatment can work to stimulate the ovaries.

· Metformin. This oral medication for type 2 diabetes improves insulin resistance and
lowers insulin levels. If you don't become pregnant using clomiphene, your doctor might
recommend adding metformin. If you have prediabetes, metformin can also slow the
progression to type 2 diabetes and help with weight loss.

· Gonadotropins. These hormone medications are given by injection.

To reduce excessive hair growth, your doctor might recommend:

· Birth control pills. These pills decrease androgen production that can cause excessive
hair growth.

· Spironolactone (Aldactone). This medication blocks the effects of androgen on the

skin. Spironolactone can cause birth defects, so effective contraception is required while
taking this medication. It isn't recommended if you're pregnant or planning to become
pregnant.

· Eflornithine (Vaniqa). This cream can slow facial hair growth in women.

· Electrolysis. A tiny needle is inserted into each hair follicle. The needle emits a pulse
of electric current to damage and eventually destroy the follicle. You might need multiple
treatments.

To help decrease the effects of PCOS, try to:

· Maintain a healthy weight. Weight loss can reduce insulin and androgen levels and
may restore ovulation. Ask your doctor about a weight-control program, and meet regularly
with a dietitian for help in reaching weight-loss goals.

· Limit carbohydrates. Low-fat, high-carbohydrate diets might increase insulin levels.

Ask your doctor about a low-carbohydrate diet if you have PCOS. Choose complex
carbohydrates, which raise your blood sugar levels more slowly.

· Be active. Exercise helps lower blood sugar levels. If you have PCOS, increasing your
daily activity and participating in a regular exercise program may treat or even prevent
insulin resistance and help you keep your weight under control and avoid developing
diabetes.

5. Prognosis for pregnancy.

Prognosis is bad. It is leads to other complications.

women with PCOS are at increased risk of developing:

type 2 – a lifelong condition that causes a person's blood sugar level to become too high

depression and mood swings – because the symptoms of PCOS can affect your confidence
and self-esteem

high blood pressure and HDLl – which can lead to heart disease and stroke

sleep apnoea – overweight women may also develop sleep apnoea, a condition that causes
interrupted breathing during sleep

· Women who have had absent or very irregular periods (fewer than 3 or 4 periods a
year) for many years have a higher than average risk of developing cancer of the womb
linning
· But the chance of getting endometrial cancer is still small and can be minimised using
treatments to regulate periods, such as the ccontraceptive pill or an intrauterine system.

Case 7 Amenorrhea

The girl, 14 years old, was hospitalized because of acute pains in the down part of
abdomen. During the last year she had monthly pain. The secondary sexual characteristics are
well-developed. No menstruation. After all manipulations the doctors put the following
diagnose: atresia of hymen, hematocolpos.
1. Make the diagnosis
2. Specify your tactics
3. What kind of amenorrhea the girl might have?

1. Make the diagnosis

cryptomenorrhoea(false) due to (Vaginal Imperforated hymen) disorders of outflow tract or

uterus.

2. Specify your tactics

Diagnostic methods-

· During your appointment, your doctor will perform a pelvic exam to check for any
problems with your reproductive organs. If you've never had a period, your doctor may
examine your breasts and genitals to see if you're experiencing the normal changes of
puberty.

· Amenorrhea can be a sign of a complex set of hormonal problems. Finding the

underlying cause can take time and may require more than one kind of testing.

Lab tests

· Pregnancy test.
· Thyroid function test.

· Ovary function test- follicle-stimulating hormone (FSH)

· Prolactin test

· Male hormone test.

Imaging tests

· Ultrasound.
· Computerized tomography (CT).

· Magnetic resonance imaging (MRI).

Treatment
· Main management is – incise the membrane

· And alsoTreatment depends on the underlying cause of your amenorrhea. In some

cases, contraceptive pills or other hormone therapies can restart your menstrual cycles.
Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. If a
tumor or structural blockage is causing the problem, surgery may be necessary.

Lifestyle and home remedies

- lifestyle factors

Keep a record of when your periods occur.

3. What kind of amenorrhea the girl might have?

· Primary amenorrhea because she is having atresia of hymen with hematocolpos. This
is feature of disorders of outflow tract or uterus.

Case 7.2 Amenorrhea

The girl is 17 years old. She complained of a lack of menstruation. Objectively:

development according to the female type, according to age. The external genitalia are
developed correctly, the vagina is nulliparous. The dome of the vagina ends blindly.
According to ultrasound, the ovaries are normal in size, in the area of the uterus, a
rudimentary cord.
1. Make the diagnosis
2. Specify your tactics
3. What kind of amenorrhea the girl might have?

1. Make the diagnosis

Diagnosis is- - cryptomenorrhoea(false) due to absence or hypoplasia of the vagina.

2. Specify your tactics

Diagnostic methods

· medical history and a physical exam.

· Pelvic exam- doctor should examine the all the reproductive organs.
· Blood tests.

· Ultrasound.

· Magnetic resonance imaging (MRI).

Treatments-

Main management is -Create functional vagina by surgery or dilators

to facilitate sexual intercourse-self-dilation methods- surgical vaginoplasty to lengthen the

vagina.

· Surgery is indicated when there is inability or reluctance to perform self-dilation,

3. What kind of amenorrhea the girl might have?

Primary amenorrhea- due to absence or hypoplastic vagina.

Case 8 Dysmenorrhea
 Female ,23 years old, unmarried had pain in the lower abdomen during menstruation every
cycle from menarche. The patient usually have the pain one or two days before the period
and there is no pain
afterwards. . The pain is unpalpable and sometimes the pain acuity to swoon. Pain can spread
over the whole abdomen, lumbosacral region Also she has a distending pain on the two sides
of the head .Feeling uncomfortable in the chest and back. Edema of eyelids during
menstruation .There is feeling of emotional depression ,migratory distending pain in the
chest ,hypochondria, ,relief of pain after discharge of clots.
Objective examination, ultrasound, laboratory investigations, hysteroscopy did not reveale
any pathology
Make the primary diagnosis
Recommend the treatment

1.Make the primary diagnosis

· DIAGNOSIS IS -pre menstrual syndrome

2.Recommend the treatment

cocp

cognitive behavioural therapy

oestradiol patches

· GnRH Analogues+add-back HRT{CONTINUOUS COMBINED ESTROGEN AND

PROGESTOGEN OR TIBOLONE}

total abdominal hysterectomy and bilateral oophrectomy

· Antidepressants. Selective serotonin reuptake inhibitors (SSRIs)

· Nonsteroidal anti-inflammatory drugs (NSAIDs). T

· Diuretics.

· Hormonal contraceptives.

Case 8.2 Dysmenorrhea

A woman, 28 years old, single, had pain in the lower abdomen during menstruation every
cycle from menarche. The patient usually experiences pain one or two days before
menstruation and there is no pain after that. The pain is not palpable, and sometimes
worsens. The pain can spread to the entire abdominal cavity, lumbosacral region. In
addition, she experiences severe abdominal pain. Sometimes nausea and vomiting. Swelling
of the eyelids during menstruation. There is a feeling of emotional depression, migrating
tensile pains in the chest, hypochondrium, pain relief after clotting.
Objective examination, ultrasound, laboratory tests, hysteroscopy did not reveal pathology
Make an initial diagnosis
I recommend treatment.

1. make the primary diagnosis

DIAGNOSIS IS -pre menstrual syndrome

2. Recommend the treatment

cocp

cognitive behavioural therapy

oestradiol patches

· GnRH Analogues+add-back HRT{CONTINUOUS COMBINED ESTROGEN AND

PROGESTOGEN OR TIBOLONE}

total abdominal hysterectomy and bilateral oophrectomy

· Antidepressants. Selective serotonin reuptake inhibitors (SSRIs)

· Nonsteroidal anti-inflammatory drugs (NSAIDs). T

· Diuretics.

· Hormonal contraceptives.

Case 9 Premenstrual Syndrome

The patient of 26 years old present complaints about the aggravation taking place five
days prior to menses: edemas (swelling), weight gain, a sense of strain, morbidity of
mammary glands, irritability, poor mood and headache. At the beginning of the next regular
menses the complaints disappear.
The gynecological observation did not show any pathological changes.
1. Make the diagnosis.
2. Determine your tactics.
3. Answer questions (one or more correct answers are possible):
What hormone represents the key factor in the etiology of this particular state?
a. Estrogens.
b. Androgens.
c. Glucocorticoids.
d. Progesterone.
1. Make the diagnosis.

DIAGNOSIS IS- pre menstrual syndrome.

2. Determine your tactics.

Diagnosis

There are no unique physical findings or lab tests to positively diagnose premenstrual
syndrome. Your doctor may attribute a particular symptom to PMS if it's part of your
predictable premenstrual pattern.

To help establish a premenstrual pattern, your doctor may have you record your signs and
symptoms on a calendar or in a diary for at least two menstrual cycles. Note the day that you
first notice PMS symptoms, as well as the day they disappear. Also be sure to mark the days
your period starts and ends.

Certain conditions may mimic PMS, including chronic fatigue syndrome, thyroid disorders
and mood disorders, such as depression and anxiety. Your health care provider may order
tests, such as a thyroid function test or mood screening tests to help provide a clear diagnosis.

Treatment

FIRST LINE-

· LIFE STYLE MODIFICATION

· COCP

· SSRI

· COGNITIVE BEHAVIOURAL THERAPY

SECOND LINE-

· OESTRADIOL PATCHES PLUS ORAL PROGESTOGEN OR LNG-IUS

· SSRIS,HIGH DOSE

· CONTINUOUS OR LUTEAL PHASE

THIRD LINE-

· GnRH Analogues+add-back HRT{CONTINUOUS COMBINED ESTROGEN AND

PROGESTOGEN OR TIBOLONE}

FOURTH LINE-

· TOTAL ABDOMINAL HYSTERECTOMY AND BILATERAL

OOPHRECTOMY+HRT {INCLUDING TESTOSTERONE

For many women, lifestyle changes can help relieve PMS symptoms. But depending on the
severity of your symptoms, your doctor may prescribe one or more medications for
premenstrual syndrome.

The success of medications in relieving symptoms varies among women. Commonly

prescribed medications for premenstrual syndrome include:

· Antidepressants. Selective serotonin reuptake inhibitors (SSRIs) — which include

fluoxetine (Prozac, Sarafem), paroxetine (Paxil, Pexeva), sertraline (Zoloft) and others —
have been successful in reducing mood symptoms. SSRIs are the first line treatment for
severe PMS or PMDD. These medications are generally taken daily. But for some women
with PMS, use of antidepressants may be limited to the two weeks before menstruation
begins.
· Nonsteroidal anti-inflammatory drugs (NSAIDs). Taken before or at the onset of your
period, NSAIDs such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve) can
ease cramping and breast discomfort.

· Diuretics. When exercise and limiting salt intake aren't enough to reduce the weight
gain, swelling and bloating of PMS, taking water pills (diuretics) can help your body shed
excess fluid through your kidneys. Spironolactone (Aldactone) is a diuretic that can help ease
some of the symptoms of PMS.

· Hormonal contraceptives. These prescription medications stop ovulation, which may

bring relief from PMS symptoms.

Lifestyle and home remedies

You can sometimes manage or reduce the symptoms of premenstrual syndrome by making
changes in the way you eat, exercise and approach daily life. Try these tips:

Modify your diet

· Eat smaller, more-frequent meals to reduce bloating and the sensation of fullness.

· Limit salt and salty foods to reduce bloating and fluid retention.

· Choose foods high in complex carbohydrates, such as fruits, vegetables and whole
grains.

· Choose foods rich in calcium. If you can't tolerate dairy products or aren't getting
adequate calcium in your diet, a daily calcium supplement may help.

· Avoid caffeine and alcohol.

Incorporate exercise into your regular routine

Engage in at least 30 minutes of brisk walking, cycling, swimming or other aerobic activity
most days of the week. Regular daily exercise can help improve your overall health and
alleviate certain symptoms, such as fatigue and a depressed mood.

Reduce stress
· Get plenty of sleep.
· Practice progressive muscle relaxation or deep-breathing exercises to help reduce
headaches, anxiety or trouble sleeping (insomnia).

· Try yoga or massage to relax and relieve stress.

3. Answer questions (one or more correct answers are possible):

What hormone represents the key factor in the etiology of this particular state?

a. Estrogens.

d. Progesterone.

Case 9.2 Premenstrual Syndrome

Woman 35 years old. Complaints of irritability, headache, memory loss, tension,

enlargement and tenderness of the mammary glands, all these phenomena appear two weeks
before menstruation.

Anamnesis: considers himself ill for two years. Two years divorced from her husband back,
after that all these phenomena appeared. Menstruation from 14 years old, without features.
Childbearing function - there were two urgent births and three medical abortion. Past
diseases - vegetovascular dystonia, cholecystitis.

Objectively: a woman of low nutrition, depressed mood, blood pressure 110 \ 70 mm RT.
Art. The mammary glands are tense, painful on palpation. From the internal organs
pathology is not detected.

1. Identify a woman’s problems.

2. Formulate a diagnosis and justify it.

3. What additional research methods are needed in this case?

4. Define tactics.
1. Identify a woman’s problems.

· irritability

· headache

· memory loss

· tension

· enlargement and tenderness of the mammary glands, all these phenomena appear two
weeks before menstruation.

· Two years divorced from her husband back, after that all these phenomena appeared

· there were two urgent births and three medical abortion

2. Formulate a diagnosis and justify it.

· DIAGNOSIS IS- Premenstrual Dysphoric Disorder. Because the patient Complaints of

irritability, headache, memory loss, tension, enlargement and tenderness of the mammary
glands, all these phenomena appear two weeks before menstruation.then we can suspect this
is due to PMS OR PMDD.

· Two years divorced from her husband back, after that all these phenomena
appeared.so this means by she is having a severe depression and stress. Menstruation from 14
years old, without features. According to this, we can say Her menstruation is normal during
puberty. Childbearing function - there were two urgent births and three medical abortion.
PMDD usually occurs during child bearing age.and her Past diseases - vegetovascular
dystonia, cholecystitis. So these symptoms leads to GIT tract problems and neurologic and
vascular symptoms disorders.so we can say that she is having PMDD.

· Objectively: a woman of low nutrition, depressed mood, blood pressure 110 \ 70 mm

RT.her blood pressure is little bit low.Art.The mammary glands are tense, painful on
palpation.the breast problems are due to the fluid reterntion problems. From the internal
organs pathology is not detected.in PMDD we can not see any objective findings.

3. What additional research methods are needed in this case?

medical history and physical and pelvic exam,

symptoms must be present:

Depressed mood
Anger or irritability
Trouble concentrating
Lack of interest in activities once enjoyed
Moodiness
Increased appetite
Insomnia or the need for more sleep
Feeling overwhelmed or out of control

4. Define tactics.

PMDD Diagnosis

· If you have any of the classic PMDD symptoms, see your doctor. They’ll go over your
medical history with you and give you a thorough exam. The doctor will do some tests to
find out how you’re feeling emotionally and mentally.

· Before they diagnose you with premenstrual dysphoric disorder, the doctor will make
certain that emotional problems, such as depression or panic disorders, aren’t causing your
symptoms. They’ll also rule out other medical or gynecological conditions, like
endometriosis, fibroids, menopause, and hormone problems.

Your doctor can diagnose you with PMDD if:

You have at least five of the symptoms listed above.

They start 7-10 days before you get your period.
They go away shortly after you start bleeding.
If you’re dealing with these issues daily and they don’t get better when your period starts, it’s
unlikely that PMDD is to blame.

PMDD Treatment

· Many of the same things you do to manage PMS can ease your PMDD symptoms.

· Two type of medication may help with PMDD: those that affect ovulation and those
that impact the central nervous system (CMS).

Examples include the use of:

SSRI antidepressents such as fluoxetine (Prozac, Sarafem), sertraline (Zoloft), paroxetine

(Paxil), and citalopram (Celexa)
oral contraceptives that contain drospirenone and ethinyl estradiol
gonadotropin-releasing hormone analogs such as leuprolide (Lupron), nafarelin (Synarel) and
goserelin (Zoladex)
danazol (Danocrine)
Birth control pills. The FDA has approved a birth control pill containing drospirenone (droh-
SPIR-uh-nohn) and ethinyl estradiol (ETH-uh-nil es-truh-DEYE-ohl), to treat PMDD.
Over-the-counter pain relievers may help relieve physical symptoms, such as cramps, joint
pain, headaches, backaches, and breast tenderness. These include:

ibuprofen
naproxen
Aspirin
Cognitive therapy (CT) has been shown to help those with PMS. Combined with
medication, CT may also help those with PMDD.

Supplements
A number of supplements have been recommended for treating premenstrual symptoms, but
studies are lacking to support efficacy and long-term safety with their use.

Examples include:

chasteberry extract to relieve physical symptoms

evening primrose oil
magnesium oxide
dietary supplementation with calcium,vitamin B6, magnesium, and vitamin E
that vitamin D and calcium supplements can reduce the both severity of symptoms, and the
risk of PMS, as well as protecting from osteoporosis. It is possible that this could also,
therefore, help with PMDD.

Chasteberry supplements are available for purchase online, but it is a good idea to speak to a
health professional before taking supplements.

Alternative remedies
Possible alternative remedies that have been tried for PMS and may help with PMDD
include:

yoga
qi therapy
saffron therapy
guided imagery
photic stimulation
acupuncture
However, more research is needed to confirm the effectiveness of these treatments.

Diet and exercise

Dietary changes include:

decreasing intake of sugar, salt, caffeine, and alcohol

increasing protein and intake of complex carbohydrates
Exercise, stress management techniques, and help in viewing menstruation in a positive light
may help.

Case 10 Infertility

The patient of 30 years old addressed to the maternity welfare centre on the subject of
infertility. The menses take place since age 15 at 28 days interval, length 4-5 days, regular,
moderately morbid during the first two days.
The first pregnancy took place 7 years ago, ended with medical abortion after the
term of 7-8 weeks. Following the abortion the patient stayed in hospital for14 days having the
acute bilateral inflammatory process of ovaries. Exacerbations with two years interval, the
appropriate hospital treatment of this is conducted.
1. What is the supposed cause of infertility for this patient?
2. What clinical data can confirm the diagnosis?
3. The volume of medical examination in women’s consultation clinic and in hospital.
4. The treatment.

) a bilateral tubectomy to treat the bilateral inflammatory processes, lead to infertility.

2) The medical abortion

Bilateral inflammatory processes that were treated with required medical procedures.

3) Laparoscopy

Hysteroscopy

Pneumosalpingography
Phenolsulfonphthalein (PSP) testing

4) In-vitro fertilization

Reverse tubectomy.

Case 10 Infertility

A patient presents to you for evaluation of infertility. She is 26 years old and has
never been pregnant. She and her husband have been trying to get pregnant for 2 years. Her
husband had a semen analysis and was told that everything was normal. The patient has a
history of endometriosis diagnosed by laparoscopy at age 17. At the time she was having
severe pelvic pain and dysmenorrhea. After the surgery the patient was told she had a few
small implants of endometriosis on her ovaries and fallopian tubes and several others in the
posterior cul-de-sac. She also had a left ovarian cyst, filmy adnexal adhesions and several
subcentimeter serosal fibroids.
1. What is the supposed cause of infertility for this patient?
2. What clinical data can confirm the diagnosis?
3. The volume of medical examination in women’s consultation clinic and in hospital.
4. The treatment.

) primary infertility, history of endometriosis, which may have caused the infertility.

2) She didn't have previous pregnancies and she has been trying for 2 years to conceive.

Her husband was confirmed to have no problems with fertility.

She had history of endometriosis and several other problems in the reproductive system.

3) Hysterosalpingography
Hysteroscopy

Laparoscopy

Ultrasound examination

Ovarian reserve testing

4) In-vitro fertilization

Stimulating ovulation with fertility drugs such as progestins

Surgery to restore fertility

Case 11 Medical contraception and family planning

A woman who is 34 years old came to the hospital for advice on contraception. She has a
stable partner, an active sexual life, a regular menstrual cycle but complained of
dysmenorrhea and she does not smoke. Genetic screening for thromboembolism was carried
out on her and she has no risk of thromboembolism or any other disease.

Question
1. What method of contraception would you recommend for her?
2. What are the advantages of this method to the patient?
3. List some other advantages of this method.
4. What are the disadvantages of this method?

1) Hormonal contraception

2) This patient has dysmenorrhea and therefore hormonal methods can reduce pain.
Fewer or no periods which also helps in dysmenorrhea.

3) Reduced bleeding and cramping with periods, lowers the risk of anemia.

Reduced risk of pelvic inflammatory disease

Reduced fibrocystic breast changes

Reduced risk of ectopic pregnancy

May reduce acne

May reduce ovarian cysts

May reduce symptoms of endometriosis

May protect against ovarian and endometrial cancer

Can be used after an abortion

4) Does not protect against sexually transmitted infections or HIV

May not be as effective when taken with certain medicines

May delay return of normal cycles

Pills must be taken every day.

Patches may not fully protect you from pregnancy if they are exposed to direct sun or
high heat. This can release a high dose of hormone from the patch, which leaves less
for the patch to release later in the week.

Patches deliver more estrogen than low-dose birth control pills do. Some research has
found that women using the patch are more likely to get dangerous blood clots in the
legs and lungs. The risk may be higher if you smoke or have certain health problems.
 The U.S. Food and Drug Administration (FDA) suggests that you talk to your doctor
about your risks before using the patch.

Case 11 Medical contraception and family planning

A woman who is 19 years old came to the hospital for advice on contraception. She has not a
stable partner, an active sexual life, a regular menstrual cycle but complained of
dysmenorrhea and she does not smoke. Genetic screening for thromboembolism was carried
out on her and she has no risk of thromboembolism or any other disease.

Question
1. What method of contraception would you recommend for her?
2. What are the advantages of this method to the patient?
3. List some other advantages of this method.
4. What are the disadvantages of this method?

) Chemical contraception, along with other barrier methods like condoms.

2) The patient sexually active and has no stable partner, so she requires protection
from STD.

3) Easy insertion.

Lubricating properties.

Use along or with condom

4) Allergic reaction.

Short duration of action.

Short time to wait for dispersion.

Inability to correctly place.