Gynacology

1. History taking and physical examination on gynecology (pp 223- 229)

2. Benign condition of the upper genital tract (pp 233- 238)
3. Lesions of the ovary (pp 238- 239)
4. Endometriosis (pp 239- 241)
5. Abnormal uterine bleeding (pp 241- 242)
6. Heavy menstrual bleeding (pp 242- 245)
7. Secondary amenorrhoea and oligomenorrhoea (pp 245- 249)
8. Dysmenorrhea and premenstrual syndrome (pp 249- 251)
9. Disorders of puberty (pp 251- 258)
10. Benign conditions of the lower genital tract (pp 259- 261)
11. Neoplastic lesions of the vaginal epithelium (pp 261- 261)
12. Emergency gynecology (pp 261- 264)
13. Infertility: classification, causes, history and investigations (pp 265- 272)
14. Treatment of infertility (pp 272- 275)
15. Bleeding in early pregnancy (pp 277- 282)
16. Ectopic pregnancy (pp 282- 286)
17. Trophoblastic disease (pp 286- 287)
18. Vomiting in early pregnancy (pp 287- 290)
19. Contraception (pp 291- 303)
20. Termination of pregnancy (pp 303- 305)
21. Lower genital tract infections (pp 305- 309)
22. Upper genital tract infections (pp 309- 312)
23. Disorders of sexual dysfunction (pp 313- 315)
24. Neoplastic lesions of the vulva and the vagina (pp 317- 321)
25. Lesions of the cervix (pp 321- 327)
26. Malignant disease of the uterus (pp 328- 331)
27. Benign ovarian tumours (pp 331- 335)
28. Ovarian malignancy (pp 335- 338)
29. Principles of palliative care in gynecological cancer (pp 338- 340)
30. Uterovaginal prolapse (pp 341- 348)
31. Urinary tract disorders in women (pp 348- 356)
 Jennifer Chayo

Topic 1: History taking and physical examination on gynecology (pp 223- 229)

General information:
 Details of the patient’s name, age and occupation.
 The age influence the likely diagnosis for a number of presenting problems.
 Occupation may be relevant both to the level of understanding that can be assumed and the
impact of different gynaecological problems on the patient’s life.
 Essential to obtain a detailed sexual history from a young woman.
The presenting complaint
 The describe the nature of her problem, and a simple statement of the presenting symptoms.
 It is important to ascertain the timescale of the problem, the circumstances surrounding the
onset of symptoms and their relationship to the menstrual cycle and the degree of disability.
 Disorders of menstruation are the commonest reason for gynaecological referral and a full
menstrual history should be taken from all women of reproductive age
 Other common presenting symptom is abdominal pain, the history must include details of the
time of onset, the distribution and radiation of the pain and the relationship to the periods.
 If vaginal discharge is the presenting symptom the colour, odour and relationship to the
periods should be noted. It may also be associated with vulval pruritus, particularly in the
presence of specific infections
 The presence of an abdominal mass may be noted by the patient or may be detected during
the course of a routine examination. Symptoms may result from pressure of the mass on
adjacent pelvic organs, such as the bladder and bowel.
 Vaginal and uterine prolapse are associated with symptoms of a mass protruding through the
vaginal introitus or difficulties with micturition and defecation.
 Common urinary symptoms include frequency of micturition, pain or dysuria, incontinence
and haematuria.
 Where appropriate, a sexual history should include reference to the coital frequency, the
occurrence of pain during intercourse (dyspareunia) and functional details relating to libido,
sexual satisfaction and sexual problems

Menstrual history
 The first question that should be asked is the date of the last menstrual period.
 The time of onset of the first period, the menarche, commonly occurs at 12 years of age and
can be considered to be abnormally delayed over 16 years or abnormally early at 9 years.
o The absence of menstruation in a girl with otherwise normal development by the age
of 16 is known as primary amenorrhoea.
o The term should be distinguished from the pubarche, which is the onset of the first
signs of sexual maturation. Characteristically, the development of breasts and nipple
enlargement predates the onset of menstruation by approximately 2 years.
 The length of the menstrual cycle is the time between the first day of one period and the first
day of the following period. Whilst there is usually an interval of 28 days, the cycle length may
vary between 21 and 42 days in normal women and may only be significant where there is a
change in menstrual pattern.
o It is important to be sure that the patient does not describe the time between the
last day of one period and the first day of the next period, as this may give a false
impression of the frequency of menstruation.
o Absence of menstruation for more than 6 months in a woman who has previously
had periods is known as secondary amenorrhoea.
o Oligomenorrhoea is the occurrence of 5 or fewer menstrual periods over 12 months.
o The amount and duration of the bleeding may change with age but may also provide
a useful indication of a disease process.
 Normal menstruation lasts from 4 to 7 days, and normal blood loss varies
between 30 and 80 mL.
 A change in pattern is often more noticeable and significant than the actual
time and volume of loss.

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 Abnormal uterine bleeding (AUB) is any bleeding disturbance that occurs between menstrual
periods or is excessive or prolonged.
o Intermenstrual bleeding is any bleeding that occurs between clearly defined cyclical,
regular menses.
o Postcoital bleeding is non-menstrual bleeding that occurs during or after sexual
intercourse.
o The term heavy menstrual bleeding (HMB) is now used to describe any excessive or
prolonged menstrual bleeding irrespective of whether the cycle is regular
(menorrhagia) or irregular (metorrhagia).
 The cessation of periods at the end of menstrual life is known as the menopause and bleeding
which occurs more than 12 months after this is described as postmenopausal bleeding.
 History of irregular vaginal bleeding or blood loss that occurs after coitus or between periods
should be noted.

Previous gynaecological history

 A detailed history of any previous gynaecological problems and treatments and surgeries.
 The amount of detail needed about previous pregnancies will depend on the presenting
problem; the number of previous pregnancies and their outcome (miscarriage, ectopic or
delivery after 20 weeks) are all that is required.
 For all women of reproductive age who are sexually active it is essential to ask about
contraception; Important to determine the possibility of pregnancy, the method of
contraception used may be relevant to the presenting complaint, e.g. irregular bleeding may
occur on the contraceptive pill or when an intrauterine device is present.
 For women over the age of 25 years ask about the date and result of the last cervical smear.

Previous medical history

 This description should take particular account of any history of chronic lung disease and
disorders of the cardiovascular system, as these are highly relevant where any surgical
procedure is likely to be necessary.
 A record of all current medications (including non-prescription and alternative treatments)
and any known drug allergies should be made.
 If she is planning a pregnancy in the near future check if she is taking folic acid supplements.
 Smoking, alcohol and other recreational drug use.

Examination
 A general examination should always be performed at the first consultation, including
assessment of pulse, blood pressure and temperature; Body weight and height.
 The distribution of facial and body hair is often important, as hirsutism may be a presenting
symptom of various endocrine disorders.
 Before starting the examination explain what will be involved in vaginal examination and
verbal consent should be obtained and documented. A chaperone should generally be present
irrespective of the gender of the gynaecologist.
Breast examination
 Should be performed if there are symptoms or at the first consultation in women over the age
of 45 years.
 The presence of the secretion of milk at times not associated with pregnancy, known as
galactorrhoea, may indicate abnormal endocrine status.
 Systematic palpation with the flat of the hand should be undertaken to exclude the presence
of any lumps in the breast or axillae
Examination of the abdomen
 Inspection of the abdomen may reveal the presence of a mass.
 Distribution of body hair, and the presence of scars, striae and hernias.
 Palpation of the abdomen should take account of any guarding and rebound tenderness,
radiation of any pain in the abdomen, and palpation for organomegaly.
 If there is a mass, try to determine if it is fixed or mobile, smooth or regular, and if it arises
from the pelvis.

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 Check the hernial orifices and feel for any enlarged lymph nodes in the groin.
Pelvic examination https://www.youtube.com/watch?v=_2QVO4puEJ4&t=182s
 Pelvic examination should not be considered an automatic and inevitable part of every
gynaecological consultation.
 The patient should be examined resting supine with the knees drawn up and separated or in
stirrups in the lithotomy position.
o Parting the lips of the labia minora with the left hand, look at the external urethral
meatus and inspect the vulva for any discharge, redness, ulceration and old scars.
o Speculum examination is performed before digital examination to avoid any
contamination with lubricant. (A bivalve or Cusco’s speculum is most commonly
used, and enables a clear view of the cervix to be obtained).
o Holding the lips of the labia minora open with the left hand, insert the speculum into
the introitus with the widest part dimension of the instrument in the transverse
position as the vagina is widest in this
o direction. When the speculum reaches the top of the vagina gently open the blades
and visualize the cervix check for the presence of any discharge or bleeding from the
cervix and of any polyps or areas of ulceration.
 Remember that the appearance of the cervix is changed after childbirth
with the external os more irregular and slit like!
o The commonest finding is of a so-called erosion or ectropion: area of cervical
epithelium around the cervical os that appears a darker red colour than the smooth
pink of the rest of the cervix. It is not an erosion at all, but normal columnar
epithelium extending from the endocervical canal onto the ectocervix.
o If the clinical history suggests possible infection, take swabs from the vaginal fornices
and cervical os and place in transport medium to look for Candida, Trichomonas and
Neisseria and take a separate swab from the endocervix for Chlamydia.
o Where vaginal wall prolapse is suspected, a Sims’ speculum should be used, provides
a clearer view of the vaginal walls.
Bimanual examination
 Bimanual examination is performed by introducing the middle finger of the examining hand
into the vaginal introitus and applying pressure towards the rectum, and as the introitus
opens, the index finger is introduced as well.
 The cervix is palpated and has the consistency of the cartilage of the tip of the nose.
o The abdominal hand is used to compress the pelvic organs on to the examining
vaginal hand.
 The size, shape, consistency and position of the uterus must be noted.
o The uterus is commonly pre-axial or anteverted, but will be postaxial or retroverted
in some 10% of women.
 Feel the pouch of Douglas for the presence of thickening or nodules, and then to palpate
laterally in both fornices for the presence of any ovarian or tubal masses.
 The ovaries may be palpable in the normal pelvis if the patient is thin, but the Fallopian tubes
are only palpable if they are significantly enlarged.
 In a child or in a woman with an intact hymen, speculum and pelvic examination is usually not
performed! (unless as part of an examination under anaesthesia).
Rectal examination
 Rectal examination may be indicated if there are symptoms such as change of bowel habit or
rectal bleeding, which may suggest bowel disease.
 It is occasionally used as a means of assessing a pelvic mass and in conjunction with a vaginal
examination can provide additional information about disease in the rectovaginal septum.

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Topic 2: Benign condition of the upper genital tract (pp 233- 238)

Congenital Anomalies
 Congenital anomalies arise from the failure of Mullarian fusion, or absence or partial
development of one or both ducts. Anomalies range from minor indentation of the uterine
fundus to a full separation of each uterine horn and cervix; associated with vaginal septa.
 Most anomalies are asymptomatic and diagnosed in relation to complications of pregnancy.
 The presence of a vaginal septum may result in dyspareunia and postcoital bleeding.
 The presence of a double uterus may also be established at routine vaginal examination, when
a double cervix may be seen.
 The separation of the uterine horns is sometimes palpable on bimanual vaginal examination,
but in most cases the uterus feels normal and there is a single cervix.
 The abnormality of two uterine horns and one cervix is known as uterus bicornis unicollis.
 The complications of pregnancy include:
o recurrent miscarriage; there is an association with cervical incompetence, which may
lead to mid-trimester miscarriage, usually associated with the subseptate uterus and
is not common in the unicornuate uterus or in uterus bicornis bicollis
o premature labour
o malpresentation
o retained placenta.
 Many are asymptomatic, the diagnosis is coincidental finding and requires no treatment or
intervention; When the diagnosis made by the history, further investigation should include
hysterography and hysteroscopy.
 The role of surgical reconstruction of a double uterus in women with infertility is difficult to
assess; The operation of plastic reconstruction of the uterus with unification of two uterine
horns or excision of the uterine septum is known as metroplasty. If there is a septum, it is
simply divided by diathermy through a hysteroscope or by an open approach.
Endometrial polyps
 Localized overgrowths of the surface endometrium.
o Grossly, they are smooth, cylindrical structures, tan to yellow in colour after removal.
o Microscopically, they consist of a fine fibrous tissue core covered by columnar
epithelium glands. Occasionally the endometrial surface develops simple or complex
hyperplasia and rarely malignant change occurs.
 They appear at any age from the early reproductive years throughout postmenopausal period.
 Usually benign lesions, but have been implicated in subfertility, as removal of these lesions
may improve rates of pregnancy and/or reduce pregnancy loss.
 Usually asymptomatic lesions, but they may contribute to abnormal uterine bleeding
manifesting as either intermenstrual bleeding, heavy menstrual bleeding or postmenopausal
bleeding; Protrusion of the polyp through the cervix may result in postcoital bleeding.
 This is detected during the investigation for abnormal uterine bleeding and infertility.
o If the polyp protrudes through the cervix, it may be difficult to distinguish from an
endocervical polyp;
o Can visualized on US; most easily detected in the secretory phase of the menstrual
cycle when the nonprogestational type of glands in the polyp stand out in contrast to
the normal surrounding secretory endometrium.
 Small asymptomatic polyps may resolve spontaneously and in these cases watchful waiting
can be the treatment of choice.
 In women suffering from bleeding symptoms or infertility, surgical intervention is required-
removed by dilatation and curettage (D&C) under general anaesthesia is best performed
under hysteroscopic guidance.
Benign tumours of the myometrium
 Uterine fibroids (myomas) are the most common benign tumour of the female genital tract
and are clinically apparent in around 25% of women.
 They are smooth muscle tumours that vary enormously in size from microscope growths to
large masses that may weigh as much as 30–40 kg.
 Fibroids may be single or multiple and may occur in the cervix or in the body of the uterus.

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 There are three types of fibroids according to their anatomical location. The most common
are within the myometrium (intramural fibroids). Those located on the serosal surface that
extend outwards and deform the normal contour of the uterus are subserosal fibroids. These
may also be pedunculated and only connected by a small stalk to the serosal surface.
 Cervical fibroids are similar to other sites in the uterus. They are commonly pedunculated but
may be sessile and grow to a size that will fill the vagina and distort the pelvic organs.
 The size and site of the tumour has a considerable effect on the symptoms:
o Subserosal fibroids can put pressure on adjacent organs and cause bowel and
bladder symptoms.
o Submucosal fibroids can lead to HMB and infertility.
o Cervical fibroids have symptoms similar to other cervical polyps and, in addition,
during attempted extrusion pain can occur as well as when there is degeneration of a
fibroid or torsion of a pedunculated myoma.
 The aetiology of fibroids is not known
 Histopathology: Myomas consist of whorled masses of unstriated muscle cells and the
accompanying connective tissue.
 Some 50% of women with fibroids are asymptomatic and the condition may only be
discovered during routine pelvic examination.
o Where symptoms do occur, they are often related to the site of the fibroids. The
common presenting symptoms are as follows:
 Abnormal uterine bleeding: submucous and intramural fibroids commonly
cause HMB.
 Pain: pelvic pain is a fairly common symptom that may occur in association
with the HMB. Acute pain is usually associated with torsion of the pedicle of
a pedunculated fibroid, prolapse of a submucous fibroid through the cervix,
or so-called ‘red degeneration’
 Pressure symptoms: a large mass of fibroids may become apparent because
of palpable enlargement of the abdomen or because of pressure on the
bladder or rectum.
 Complications of pregnancy: recurrent miscarriage is more common in
women with submucous fibroids.
 Infertility: Women with uterine fibroids will have difficulty conceiving.
Submucous and intramural fibroids are more likely to impair infertility than
subserous ones.
 Management:
o Most fibroids are asymptomatic and do not require treatment. In symptomatic
women the oral contraceptive pill, progestogens and NSAIDs have no effect on the
size of fibroids but may be of value in controlling menstrual loss.
o A reduction of up to 45% in size can be achieved using GnRH analogues.
o Progesterone receptor modulator, mifepristone, has been found to be effective in
reducing blood loss and fibroid size over a 6 month period.
o Uterine artery embolization (UAE) Involves the catheterization of the uterine arteries
via the femoral artery and the injection of polyvinyl particles to reduce the blood
supply to the uterus and to the fibroids. The fibroid shrinks because of ischaemia.
Impairment of fertility may be associated with a small risk.
o Surgical treatment of choice is hysterectomy; fibroids account for about a third of all
hysterectomies. In reproductive age removal of the fibroids by surgical excision or
myomectomy
https://www.amboss.com/us/knowledge/Uterine_leiomyoma

Adenomyosis
 Adenomyosis is a condition characterized by the invasion of endometrial glands and stroma
into myometrium with surrounding smooth muscle hyperplasia.
 Typically occurs in parous women and is usually diagnosed in the 4th decade; associated with
HMB and dysmenorrhoea of increasing severity. The condition regresses after menopause.
 On clinical examination, the uterus is symmetrically enlarged and tender.
 Can be managed conservatively with medical treatment, with UAE or surgically, Prostaglandin
synthetase inhibitors may sometimes help. Hysterectomy is the surgical procedure of choice.
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Topic 3: Lesions of the ovary (pp 238- 239)

 Ovarian enlargement is commonly asymptomatic, and the silent nature of malignant ovarian
tumours is the major reason for the advanced stage of presentation.
 Ovarian tumours may be cystic or solid, functional, benign or malignant.
 Tumours of the ovary that are less than 10 cm in diameter rarely produce symptoms.
 The common presenting symptoms include:
o Abdominal enlargement: in the presence of malignant change, this may also be
associated with ascites.
o Symptoms from pressure on surrounding structures such as the bladder and rectum.
o Symptoms relating to complications of the tumour:
 Torsion: acute torsion of the ovarian pedicle results in necrosis of the
tumour; there is acute pain and vomiting followed by remission of the pain
when the tumour has become necrotic
 Rupture: the contents of the cyst spill into the peritoneal cavity and result in
generalized abdominal pain.
 Haemorrhage into the tumour is an unusual complication but may result in
abdominal pain and shock if the blood loss is severe
 Hormone-secreting tumours may present with disturbances in the
menstrual cycle. In androgen secreting tumours the patient may present
with signs of virilization. Although a greater proportion of the sex-cord
stromal type of tumour are hormonally active, the commonest type of
secreting tumour found in clinical practice is the epithelial type.
o Signs
 On inspection, the abdomen may be visibly enlarged
 Percussion over the swelling will demonstrate central dullness and
resonance in the flanks.
 These signs may be obscured by gross ascites.
 Small tumours can be detected on pelvic examination and will be found by
palpation in one or both fornices, as the tumour enlarges, it changes to
more central position and, in the case of dermoid cysts, is often anterior to
the uterus.
 Most ovarian tumours are not tender to palpation; if they are painful the
presence of infection or torsion should be suspected.
 Benign ovarian tumours are palpable separately from the uterine body and
are usually freely mobile.

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Topic 4: Endometriosis (pp 239- 241)

 Endometriosis is a disease characterized by the presence of extrauterine endometrial-like

tissue consisting of glands and stroma, often surrounded by an inflammatory response.
 It affects between 5% and 15% of reproductive age women.
 In women presenting with pelvic pain or infertility, or in adolescents with severe
dysmenorrhoea or chronic pelvic pain, the prevalence is significantly higher.
 Women suffering from endometriosis very often present with a complex of debilitating
symptoms including pelvic pain, dyspareunia, dysuria, dyschezia and dysmenorrhoea.
 Although benign, endometriosis causes a substantial burden to the woman’s
health, partly because of an average delay of 8-10 years between the onset of the
symptoms and diagnosis.
 Aberrant endometrial deposits occur in many different sites, commonly occurs in
the ovaries, the uterosacral ligaments and the rectovaginal septum.
 It may also occur in the pelvic peritoneum covering the uterus, tubes, rectum,
sigmoid colon and bladder.
 Remote ectopic deposits of endometrium may be found in the umbilicus,
laparotomy scars, hernial scars, the appendix, vagina, vulva, cervix, lymph nodes
and, on rare occasions, the pleural cavity.
 Ovarian endometriosis occurs in the form of small superficial deposits on the surface of the
ovary or as larger cysts known as endometriomas which may grow up to 10 cm in size.
o These cysts have a thick, whitish capsular layer and contain altered blood, which has
a chocolate-like appearance, chocolate cysts.
o Often densely adherent both to the ovarian tissue and to surrounding structures.
o Likely to rupture and patients present with symptoms of acute peritoneal irritation.
 Underneath the lining of the cyst, there is often:
o Broad zone containing phagocytic cells with haemosiderin.
o Broad zone of hyalinized fibrous tissue.
o Intense fibrotic reaction that surrounds the endometriosis, and this may also contain
muscle fibres.
 Diagnosis
o The initial assessment involves taking a detailed history of the duration and nature of
pelvic pain with attention to the relationship to the menstrual cycle, the presence of
bowel and bladder symptoms, the presence of dyspareunia and the impact of
posture and movement on pain.
o Initial investigations may include urinalysis, screening for sexually transmitted
infections and a transvaginal ultrasound scan.
 Ultrasound has a high degree of sensitivity and specificity for diagnosing
ovarian endometriotic cysts and deep infiltrating bowel endometriosis, but
is of little use in identifying the commoner types of peritoneal disease.
 Management
o Medical treatment involves suppression of ovulationand creating a steady hormone
environment; done by: progestogens, progestogen subdermal implants and/or the
levonorgestrel intrauterine system.
 Combined oral contraceptive pills are widely used, but it does not make
logical sense to use an oestrogen containing preparation in a woman with
an oestrogen sensitive disease; modern pills have a high progestogen-
balance and may work well.
o Danazol, gonadotrophin releasing hormone agonists and aromatase inhibitors are
second line.
o Medical therapy needs to be integrated with use of surgical therapies:
 Complete excision of visible lesions; preferable to attempted
diathermy ablation of the lesions and reduces pain and improves
quality of life.

https://www.amboss.com/us/knowledge/Endometriosis PLEASE study this topic from Amboss

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Topic 5: Abnormal uterine bleeding (pp 241- 242)

 Abnormal uterine bleeding (AUB) is any bleeding is turbance that occurs between menstrual
periods or is excessive or prolonged.
 FIGO (the International Federation of Gynecology and Obstetrics) has recently designed a
classification system for underlying causes of AUB.
 The most common menstrual abnormalities are intermenstrual (often associated with
postcoital bleeding) and heavy or irregular menstrual bleeding.

Intermenstrual bleeding (IMB)

 IMB generally occurs between clearly defined cyclical, regular menses.
 The bleeding may occur at the same time in each cycle or may be random.
o typically associated with surface lesions of the genital tract, and these women may
also experience postcoital bleeding.
o Undiagnosed pregnancy-related bleeding, including ectopic pregnancy and
hydatidiform molar disease may result in irregular bleeding mimicking IMB.
o In 1–2% of women, IMB may be physiological with spotting occurring around the
time of ovulation.
 IMB is commonly associated with use of hormonal contraception (when it is known as
unscheduled or breakthrough bleeding), particularly the combined oral contraceptive pill,
intrauterine systems and use of the progestogen-only methods including the pills and
implants.
 In women with new onset of IMB, sexually transmitted infection of the cervix or vagina should
be considered as a possible cause, especially Chlamydia.
 Less common causes are vaginitis (non-sexually transmitted), cervical ectropion, endometrial
or cervical polyps, endometritis, adenomyosis, submucous myomas and sometimes cervical or
endometrial cancers; pregnancy should always be excluded.
 Ensure that Pap smear screening is up to date, and if all these are negative then pelvic
ultrasound may reveal an intrauterine cause.

Postcoital bleeding (PCB)

 Non-menstrual bleeding that occurs during or after sexual intercourse.
 Causes include surface lesions of the genital tract, typically infection,
cervical or endometrial polyps, cervical, endometrial or vaginal cancer and
trauma.
 PCB occurs in women with cervical cancer, and if there is recurrent PCB,
with or without IMB, colposcopy examination of the cervix is recommended
even if the Pap smear is normal.

Postmenopausal bleeding
 Vaginal bleeding that occurs more than 1 year after the last natural
menstrual period is known as postmenopausal bleeding.
 The possibility of carcinoma of the body of the uterus should be considered,
and an assessment of the endometrium is advised for all women (with diagnostic
hysteroscopy and endometrial biopsy or transvaginal US measurement of the
endometrial thickness).
 When the endometrium is measured at less than 3 mm, significant
endometrial pathology is very unlikely.
 Other causes of postmenopausal bleeding include other benign and
malignant tumours of the genital tract, stimulation of the endometrium by
exogenous or endogenous oestrogen (e.g. hormone replacment therapy (HRT)
and oestrogens from ovarian tumours), infection and postmenopausal atrophic
vaginitis.

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Topic 6: Heavy menstrual bleeding (pp 242- 245)

 Heavy menstrual bleeding, defined as more than 80 mL per month of loss.

 The recommended ‘clinical’ definition of HMB is ‘excessive menstrual loss leading to
interference with the physical, emotional, social and material quality of life of a woman, and
which occurs alone or in combination with other symptoms’.
 HMB is usually caused by benign conditions, it commonly leads to iron-deficiency anaemia.
 HMB can commonly arise from an imbalance in the clotting and other regulatory molecular
factors at a local endometrial level, without the presence of obvious structural pathology.
 It can be associated with a number of benign gynaecological conditions including
leiomyomata, endometrial polyps, adenomyosis, endometrial hyperplasia and sometimes
endometrial cancer.
Causes
 Structural
o Leiomyomata are the commonest, but most women dont experience abnormal loss.
o Endometrial carcinoma is rare under the age of 40 years and is more likely initially to
cause irregular bleeding.
o Adenomyosis is associated with a uniformly enlarged tender uterus, HMB and
dysmenorrhoea.
o Endometrial polyps are a common cause but usually also cause IMB.
o Endometrial hyperplasia is a common structural lesion, and may be associated with
irregular, anovulatory cycles. It may be a premalignant condition.
 Non structural
o Disturbed ovulation or anovulation can result in very irregular, especially infrequent,
cycles with prolonged, heavy and irregular bleeding of such severity that it may
occasionally be life-threatening.
o In this situation, unopposed oestrogen often leads to the endometrium becoming
greatly thickened and hyperplastic, which eventually breaks down in a patchy and
erratic fashion.
o Most ovulatory disorders occur in the menopause transition, in adolescence or can
be traced to endocrinopathies, e.g. PCOS, hypothyroidism.
o Excessive local production of fibrinolytic factors (especially tissue plasminogen
activator), deficiencies in local production of vasoconstrictors and increased local
production of substances that promote vasodilation.
o The commonest iatrogenic cause of heavy bleeding is the presence of a copper-
bearing intrauterine contraceptive device (IUD).
History and examination
 An accurate history is essential to establish the pattern of bleeding and the duration of
symptoms.
 A recent change in the pattern of menstruation and associated pain are more likely to be
associated with the development of structural pelvic pathology.
 Pain is typically associated with adenomyosis and chronic PIC.
 General examination for signs of anaemia and thyroid disease and a pelvic examination
including cervical smear; finding of a pelvic mass on pelvic examination is most likely to
indicate the presence of uterine leiomyomata (fibroids) but may indicate a uterine
malignancy, adenomyosis or ovarian tumour.
Investigations
 A full blood count with platelets, serum ferritin and serum transferrin.
 Patients should be referred for further investigation if:
o There is a history of repeated or persistent irregular or intermenstrual bleeding, or of
risk factors for endometrial carcinoma.
o The cervical smear is abnormal.
o Pelvic examination is abnormal
o There is significant pelvic pain unresponsive to simple analgesia.
o They do not respond to first-line treatment after 6 months.
 The main methods of investigation are US, endometrial biopsy, hysteroscopy.

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 partial coagulation screen for the disorders of hemostasis – a coagulopathy – (of which mild
von Willebrand Disease) are only indicated if a screening history for coagulopathies is
suggestive or in young women.
 Hysteroscopy allows visualization of the uterine cavity using a 3 mm endoscope introduced
through the cervix.
Management
 Medical treatment: the treatment chosen will depend on whether contraception is required,
whether irregularity of the cycle is a problem and the presence of contraindications to certain
treatments; Mefenamic or tranexamic acid can be used (in case of copper IUD) or
levonorgestrel intrauterine system.
 Non-hormonal treatments: NSAIDs reduce blood loss and their analgesic have advantage if
there is associated dysmenorrhoea. Tranexamic acid is an antifibrinolytic agent that reduces
blood loss by about 50%.
 Hormonal treatments: Use of the combined oral contraceptive pill or the levonorgestrel
intrauterine system is associated with up to 90% reduction in average monthly blood loss-
recommended as the first choice!
 Surgical treatment
o Endometrial resection or ablation
o Hysterectomy (remains the definitive treatment)
 vaginal hysterectomy
 Laparoscopic hysterectomy
o Conservation of the ovaries, if normal, is usually recommended for women under the
age of 50 years undergoing hysterectomy, to avoid the onset of a surgically induced
early menopause.
o For women near the menopause this advantage has to be offset against the small
possible risk of later ovarian malignancy, and the option of oophorectomy should be
discussed.

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Topic 7: Secondary amenorrhoea and oligomenorrhoea (pp 245- 249)

Secondary amenorrhoea is the cessation of menses for 6 or more months in a woman who
has previously menstruated.
Oligomenorrhoea is the occurrence of five or fewer menstrual periods over 12 months.

Physiological causes: pregnancy and lactation account for most cases of amenorrhoea in the
reproductive years; Duration of amenorrhoea depends on the extent, frequency and length
of time of breastfeeding.
Pathological causes: can be divided into disorders of the hypothalamus, anterior pituitary,
ovary and genital tract.
 Hypothalamic disorders Functional hypothalamic amenorrhoea (FHA) is defined as
a non-organic and reversible disorder in which the impairment of GnRH pulsatile
secretion plays a key role.
o weight loss-related amenorrhoea
o stress-related amenorrhoea
o exercise-related amenorrhoea
o drugs related amenorrihoea
 Pituitary disorders: The pituitary causes of secondary amenorrhoea are most commonly the
result of high prolactin levels. Around 40% of cases are associated with a prolactin-secreting
tumour of the anterior pituitary (micro- or macroadenoma) and secretion of breast milk
(galactorrhoea) occurs in about one-third of patients. Rarely, pituitary amenorrhoea may
result from postpartum necrosis of the anterior pituitary from severe obstetric hemorrhage
and hypotension (Sheehan’s syndrome).
 Ovarian failure: Premature ovarian failure (POF) is usually defined as the cessation of ovarian
function before the age of 40 and is characterized by amenorrhoea and raised gonadotrophin
levels. Turner’s syndrome is the most common genetic cayse. Autoimmune oophoritis
associated with autoantibodies to multiple endocrine and other organs, and also been seen in
women with SLE and myasthenia gravis.
 Polycystic ovary syndrome: affects 5-10% of reproductive age women and is associated with
anovulatory disorders causing infertility and oligomenorrhea. PCOS is found in women with
symptoms of androgen excess: hirsutism and acne, overweight or obese.
The ovaries in appear enlarged and contain multiple (more than 10-12), small (<10 mm) fluid-
filled structures just under the ovarian capsule. The ovary also has a greatly increased ovarian
stroma, which may have abnormal endocrine properties.
o Biochemical investigations indicate abnormally raised LH levels and absence of the LH
surge. Oestrogen and FSH levels are normal, and as a result there is an increase in
the LH: FSH ratio; increased ovarian secretion of testosterone, androstenedione and
dehydroepiandrosterone
o Diagnosis (and criteria for the definition) is controversial. Any two of the following
three are sufficient to confirm the diagnosis:
 oligo- or anovulation
 hyperandrogenism (biochemical or clinical) and
 polycystic ovaries on ultrasound examination.
o Treatment depends on which of the presenting symptoms predominate.
 Lifestyle changes including weight loss and exercise; a loss of as little as 5%
in weight can improve the menstrual pattern, endocrine profile and fertility.
 Hirsutism can be treated by depilatory and electrolysis or antiandrogens.
 If the problem is primarily one of subfertility, then clomiphene citrate or
carefully monitored human menopausal gonadotrophin can be used to
stimulate ovulation.
 Oral hypoglycaemic control: insulin sensitizing agent, metformin.
 Consider! Prolonged unopposed oestrogen action may result in the
development of endometrial hyperplasia, which may rarely undergo
malignant change.
- Hyperplasia will often regress following the administration of a
progestational agent.

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Uterine causes
 Surgical removal of the uterus will result in secondary amenorrhoea.
 Other conditions that scar the endometrium, and cause intrauterine adhesions and loss of
menses, include infection from tuberculosis and Asherman’s syndrome.
 Cryptomenorrhoea (literally ‘hidden menstruation’): Cervical stenosis from surgical
procedures or infection can cause blockage of menses through obstruction of outflow.

Investigations in women with amenorrhoea or oligomenorrhoea

 The possibility of pregnancy should always be considered and is excluded by pregnancy test.
 The history should include details of recent emotional stress, changes in weight, menopausal
symptoms and current medication.
 The differential diagnosis is established by the measurement of FSH and LH, prolactin,
oestradiol and thyroid function tests (TFTs).
 A pelvic ultrasound can provide additional evidence of polycystic ovary syndrome, ovarian
tumours and abnormalities of the lower genital tract.
 MRI imaging of the pituitary fossa, in case there is an elevated prolactin or some unusual
features in the history suggesting other intracranial pathology.
 Progesterone challenge test: the administration of medroxyprogesterone acetate 10 mg daily
for 5 days should produce withdrawal bleeding 2-7 days after completing the course.

Management
 Outside the ‘physiological’ group, most cases are hypothalamic or PCOS in origin.
 If oestradiol levels are low and in some cases it is useful to administer cyclical oestrogen-
progestogen therapy.
 Hyper-prolactinaemia will usually respond to stopping any dopamine-inhibiting drugs or to
treatment with dopamine agonists such as cabergoline or bromocriptine.

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Topic 8: Dysmenorrhea and premenstrual syndrome (pp 249- 251)

Dysmenorrhoea or painful menstruation is the commonest of all gynaecological symptoms.

It is usually characterized as colicky pain that starts with the onset of bleeding and is maximal in the
first few days of the period.

 Primary dysmenorrhoea occurs in the absence of any significant pelvic pathology and is
caused by excessive myometrial contractions producing uterine ischemia in response to local
release of prostaglandins from the endometrium.
o It often begins with the onset of ovulatory cycles between 6 months and 2 years
after the menarche, and it may occur more frequently or be more severe in young
women whose periods start at an early age.
o The pain may be severe in some women and the intense cramping can be associated
with nausea, vomiting, diarrhoea and dizziness.
o The pain usually only occurs in ovulatory cycles, is lower abdominal and pelvic in
nature, but sometimes radiates down the anterior aspect of the thighs.
o Commonly the pain disappears or improves after the birth of the first child.
 Secondary or acquired dysmenorrhoea occurs in association with some form of pelvic
pathology and usually, but not always, has its onset sometime after the menarche.
o The pain typically precedes the start of the period by several days and may last
throughout the period. It tends to be of a heavy, dragging nature (often called
‘congestive’), and may radiate to the back, loins and legs.
o Secondary dysmenorrhea may occur as a result of endometriosis, fibroids,
adenomyosis, pelvic infections, adhesions and developmental anomalies.
o Endometriosis pain often begins with severe dysmenorrhoea in adolescence, and this
potential diagnosis should not be overlooked.

Investigations

 A careful history is important with attention to the timing of the onset and characteristics of
pain and associated symptoms, e.g. such as dyspareunia, dysuria.
 Pelvic examination is to be avoided in those women with primary dysmenorrhoea who have
never been sexually active.
o The decision to perform a vaginal examination should be individually assessed,
considering sexual activity and the need for a Pap smear.
o In women with primary dysmenorrhea there is usually no pelvic tenderness or any
abnormality on vaginal examination.
o In secondary dysmenorrhoea a pelvic examination is essential to assess uterine and
adnexal tenderness, masses and uterine mobility, as well as the posterior fornix and
cervical movement pain.
o Swabs should be taken for pelvic infection and a pelvic ultrasound organized.
o Laparoscopy is required for women with persistent or progressive pain symptoms
that are unresponsive to medical therapies.

Management

 Stop smoking; as smoking increases dysmenorrhea.

 Heat pack on the lower abdomen anecdotally provides relief.
 Dietary supplements have been investigated, with Vitamin B1 indicated to be a helpful
treatment. Exercise can be beneficial.
 NSAIDs most commonly used. Adolescents and young adults with symptoms that do not
respond to treatment within 3 menstrual periods should be offered a combined oral
contraceptive pill for the next 3 menstrual cycles (the NSAID therapy can be continued).

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Premenstrual syndrome (PMS) is defined as recurrent moderate psychological and physical symptoms
that occur during the luteal phase of the menstrual cycle and resolve with the onset of bleeding.
It affects around 20% of reproductive age women. In the more severe form, premenstrual
dysphoric disorder (PMDD), women experience somatic, psychological and behavioural symptoms.

Symptoms and signs

The symptoms associated with PMS and PMDD are:
 Physical:  Psychological
o Abdominal bloating o Anger, irritability
o Body pains o Anxiety
o Breast tenderness or fullness o Changes in appetite (increased appetite, food cravings)
o Abdominal pain and cramps o Changes in libido
o Tiredness o Decreased concentration
o Headaches o Depressed mood
o Nausea o Feelings of loss of control
o Peripheral oedema o Mood swings
o Weight gain o Poor sleep
o Withdrawal from social and work activities
Pathogenesis
 The Aetiology of PMS and PMDD are unknowm.
 women appear to be more ‘physiologically’ sensitive to changes in circulating levels of
oestrogen and progesterone, and may have altered central neurotransmitter function,
particularly for serotonin.

Management
 Clinical history is the key to diagnosis and the correct diagnosis is best established by asking
women to prospectively collect a detailed menstrual diary of their symptoms ideally over two
cycles. This will clarify whether there are non-luteal symptoms that may suggest other medical
or psychological disorders.
 Non-pharmacological options:
o increasing exercise, reducing caffeine and refined carbohydrate intake.
o Vitamin D, Vitamin B6 and evening primrose oil.
o Antiprostaglandin painkillers, i.e ibuprofen, useful for breast pain and headaches.
o Diuretics such as spironolactone may be of benefit in the small group of women who
experience true water retention.
 Pharmacological:
o The first line are the SSRIs or the SNRIs; such as sertraline, citalopram and fluoxetine,
taken either daily or during the luteal phase of the cycle, have been found to
significantly reduce the physical and psychological symptoms seen within a few
weeks of taking the medication but improvement in mood, if there is associated
depression, may take up to a month to improve.
o The combined oral contraceptive pill has been commonly used; pills containing
drospirenone, a spironolactone derivative, in a 24 day pack have a benefit compared
with taking a conventional 28 day pill with 7 day break.
o Gonadotrophin-releasing hormone agonists suppress ovarian function and relieve
symptoms during treatment.

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Topic 9: Disorders of puberty (pp 251- 258) https://www.youtube.com/watch?v=ZN2VoHMvKNA

 Puberty represents a period of significant growth and profound hormonal changes that will
lead to the development of an adult body and in most cases the ability to reproduce.
 Normal pubertal development occurs in an ordered sequence and involves acquisition of
secondary sex characteristics associated with a rapid increase in growth that culminates in
reproductive capability.
 The process is initiated by increased amounts of GnRH secreted in a pulsatile manner from the
hypothalamus, but the exact trigger of this event is not known.
o release of pulsatile GnRH leads to release of the pituitary hormones, i.e. LH and FSH.
o LH stimulates androstenedione production in the ovary and FSH estradiol synthesis.
o The pulses are initially nocturnal becoming eventually diurnal.
 Puberty is complete once oestrogen rises to the level where positive feedback occurs on the
hypothalamus and ovulatory cycles establish; process is seen to be between 18m-6yrs.
 Thelarche: Breast tissue development begins with a subareolar breast bud and occurs under
the influence of initially unopposed oestradiol; Puberty begins with breast development in
approximately 80% of girls with the others experiencing adrenarche first.
 Adrenarche: Adrenal androgen production occurs approximately 1-2y before pubarche, the
onset of puberty; It is independent of gonadarche, the maturation of the gonads and the
secretion of sex steroids, but occurs prior.
 Menarche: Reproductive maturity occurs with the onset of menstruation the average age is
12–13 years; cycles are often irregular in the first 6-18m as ovulation initially is infrequent.
 Growth spurt: The acceleration in the rate of growth accompanies or precedes pubertal
development, occurs between 9.5–14.5 years and is dependent on GH as well as gonadal
steroids; The first is lengthening of legs then increase in shoulder breadth and trunk length.
The pelvis enlarges and changes shape. Maximal height is reached between 17-18 years with
fusion of the femoral epiphyses.

Precocious puberty
 Defined as the development of the physical signs of puberty before the age of 8 years;
progresses from premature thelarche to menarche because breast tissue responds faster to
oestrogen than the endometrium.
 It is useful to categorize possible causes as central, dependent on GnRH secretion, and
peripheral, GnRH independent. The majority of cases do not have a pathological basis.
 In girls >4y specific causes are most likely idiopathic, <4y CNS causes predominate.
 Central (GnRH dependent) in order of frequency:
o Idiopathic
o CNS tumours
o Hydrocephaly
o CNS injury secondary to trauma or infection, recent or past
o CNS irradiation
o neurofibromatosis.
 GnRH stimulation test will show a pubertal, threefold response in LH levels.
 Peripheral or GnRH independent causes:
o hormonal secreting tumour of the adrenal gland or ovaries
o gonadotrophin producing tumours
o congenital adrenal hyperplasia (non-classical)
o McCune–Albright syndrome
o Hypothyroidism
o exogenous oestrogens
o follicular cysts of the ovary.
 Evaluation
o The 1st step: family history, mainly the age of onset of puberty in parents and siblings.
o The heights of both parents should be recorded and the projected height of the child
calculated.

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o The history of pubertal development needs to be documented and along with other
symptoms such as headache or visual disturbance.
o A history of illness, trauma, surgery and medications is also pertinent.
o Physical examination should include documentation of the Tanner stage and
examination for other signs to indicate a peripheral cause such as skin lesions or
ovarian masses.
o Signs of virilization must be looked for including, acne, hirsutism and clitoromegaly.
 Investigations
o This is the most important step in determining which category of precocious puberty
is responsible and narrowing the differential diagnosis.
o Plasma FSH, LH, oestradiol are essential as is a TFT.
o X-ray of the hand to determine bone age.
o US of the abdomen and pelvis looking for adrenal or ovarian tumours and to
establish normal anatomy.
 The ovary may show a multicystic appearance in normal puberty and in
cerebral and idiopathic forms.
 Follicular cysts need to be distinguished from predominantly solid oestrogen
secreting granulosa or theca cell tumours.
 Management
o The key aims of treatment are to arrest and even reverse the physical signs of
puberty and to avert the rapid development in bone age.
o The main treatment for central precocious puberty: GnRH agonist which desensitizes
the pituitary and leads to a reduction in LH and FSH output.

Variations on normal puberty

 Premature adrenarche: This refers to the secretion of adrenal androgens before age 8 years;
frequently idiopathic and non-progressive; It presents usually with complaints of axillary hair
and or pubic hair plus the emergence of body odour, sometimes with acne and hirsutism.
 Premature thelarche: Defined as breast budding prior to age 8 years, this condition requires
to be differentiated from precocious puberty. It is more common in infants and tends to
resolve spontaneously in this group.
 Precocious menarche: This is the least common of the variants and is defined as cyclic vaginal
bleeding without secondary sexual characteristics; It may be caused by a transitory rise in
oestrogen as the result of follicular activity or a heightened endometrial sensitivity

Delayed puberty
 Delayed puberty is defined by the absence of breast development in girls beyond 13 years.
 The diagnosis is also made in the absence of menarche by age 16 or within 5 years after the
onset of puberty.
 Mostly delayed puberty is constitutional, arising from inadequate GnRH from the
hypothalamus; It may also be secondary to chronic illness such as anorexia nervosa, asthma,
chronic renal disease and inflammatory bowel disease.
 Anatomic considerations such as outflow obstruction in haematocolpos need exclusion.
 The hypogonadism that characterizes this state may occur with both elevated and lowered
levels of gonadotrophins.
 Investigations:
o Physical examination: height, weight, BMI, Tanner staging and vital signs.
o FSH, LH, oestradiol, prolactin and TFTs will illustrate gonotrophin function and
ovarian response together with the major endocrine disorders .
o Pelvic US will define genital tract architecture; prepubertal uterus is difficult to see.
o If the gonadotrophins are elevated, first check the patient’s karyotype to determine
whether Turner’s syndrome, androgen sensitivity or Swyer’s syndrome is present.
 Treatment is by initially unopposed oestrogens beginning at 0.3 mg daily and slowly increasing
to facilitate adequate breast development; Once adequate growth is achieved, progesterone
should be added for endometrial protection and cyclicity.

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Topic 10: Benign conditions of the lower genital tract (pp 259- 261)

Vulval pruritus
 Pruritus or itch is the most commonly described symptom of those complaining of discomfort
in the vulval area; often accompanied by scratching with its attendant trauma to the
epithelium, may often be chronic.
 Women may experience sexual difficulties consequently and often report problems in
discussing their symptoms or seeking help.
 Diagnosis and management may be difficult for the clinician as symptoms and signs tend to
cluster, biopsy results can be equivocal and irritant or allergic reactions may develop to
various medications and remedies tried.
 The vulva, in such proximity to the vagina, may also express features of bacterial or viral
vaginitis or cervicitis with hypersensitivity reaction to productive discharge as seen in
candidiasis.
 Itchy, scaly lesions with increased vascularity or poor treatment response should be biopsied
to exclude malignancy.
 Treatment:
o Ensure irritant or allergic stimuli are removed, that the area is kept dry and well
ventilated to promote healing, and that barrier preparations to prevent repeated
insult are prescribed.
o Soap, perfumed products, talcum and flavoured lubricants should be avoided.

Vaginal discharge
 Vaginal discharge describes any fluid loss through the vagina.
 While most discharge is normal and can reflect physiological changes throughout the
menstrual cycle, some discharge can occur because of infection or trauma.
 White discharge usually occurs in response to hormonal changes at the beginning and the end
of the cycle whilst midcycle, with high oestrogen levels, the discharge is clear.

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Cervical polyps
 Benign polyps arise from the endocervix and are pedunculated, with a covering of
endocervical epithelium and a central fibrous tissue core.
 The polyps present as bright red, vascular growths that may be identified on routine
examination.
 The presenting symptoms may include irregular vaginal blood loss or postcoital bleeding.
 Less frequently, the polyps arise from the squamous epithelium, when the appearance will
resemble the surface of the vaginal epithelium.
 Small polyps can be avulsed in the outpatient clinic by grasping them with polyp forceps and
rotating through 360°. Larger polyps may need ligation of the pedicle and excision of the polyp
under general anaesthesia.

Benign tumours of the vulva and vagina

 Benign cysts of the vulva include sebaceous, epithelial inclusion and wolffian duct cysts which
arise from the labia minora and the per-urethral region, and Bartholin’s cysts.
 A rare cyst may arise from a peritoneal extension along the round ligament, forming a
hydrocele in the labium major.
 Benign solid tumours include fibromas, lipomas and hidradenomas.
 True squamous papillomas appear as warty growths and rarely become malignant.
 All these lesions are treated by simple biopsy excision.

Vaginal cysts
 Congenital
o Cysts arise in the vagina from embryological remnants; the commonest varieties are
those arising from Gartner’s duct (wolffian duct remnants).
o These are not rare and occur in the anterolateral wall of the vagina.
o Usually asymptomatic and are found on routine examination.
o The cysts are treated by simple surgical excision and rarely cause any difficulties.
 Vaginal inclusion cysts
o Inclusion cysts arise from inclusion of small particles or islands of vaginal epithelium
under the surface.
o The cysts commonly arise in episiotomy scars and contain yellowish thick fluid. They
are treated by simple surgical excision.
Endometriosis
 May appear anywhere in the vagina, but occur most commonly in the posterior fornix.
 The lesions may appear as dark brown spots or reddened ulcerated lesions.
 The diagnosis is established by excision biopsy.
 If the lesions are multiple, then medical therapy should be instituted as for lesions in other
sites.

Solid benign tumours

 These lesions are rare but may represent any of the tissues that are found in the vagina.
 Thus, polypoid tumours may include fibromyomas, myomas, fibromas, papillomas and
adenomyomas.
 These tumours are treated by simple surgical excision.

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Topic 11: Neoplastic lesions of the vaginal epithelium (pp 261- 261)
Vaginal intraepithelial neoplasia
 Vaginal intraepithelial neoplasia (VAIN) is usually multicentric and tends to be multifocal and
associated with similar lesions of the cervix.
 Precancerous lesion cause by dysplasia of squamous cells.
 The condition is asymptomatic.
 Tends to be discovered because of a positive smear test or during colposcopy for abnormal
cytology, often after hysterectomy.
 There is a risk of progression to invasive carcinoma but the disease remains superficial
 Treated by -surgical excision
-laser ablation.
-cryosurgery.

Vaginal adenosis
 Vaginal adenosis is a benign abnormality in the vagina characterized by the presence of
columnar epithelium in the vaginal epithelium which has been found in adult females
whose mothers received treatment with diethylstilbestrol (estrogen agonist. In 1971, DES was
shown to cause clear-cell carcinoma, a rare vaginal tumor, in girls and women who had
been exposed to this medication so no longer use) during pregnancy or other certain
chemicals ( other progestogens and nonsteroidal estrogens).
 The condition commonly reverts to normal squamous epithelium but in about 4% of cases the
lesion progresses to vaginal adenocarcinoma.
 Dx -colposcopy
-Biopsy needed for further diagnosis
-important to follow carefully with serial cytology.

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Topic 12: Emergency gynecology (pp 261- 264)

Pelvic infection
 Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the
upper female genital tract mainly caused by ascending infection from the cervix or vagina.
 Cause – Pathogen: Most common: Chlamydia trachomatis and Neisseria gonorrhoeae
 Risk factors: Multiple sexual partners, unprotected sex, A history of prior STIs and/or
adnexitis.
 Clinical features:
 Lower abdominal pain (generally bilateral), which may progress to acute abdomen
 Nausea, vomiting
 Fever
 Dysuria, urinary urgency
 Menorrhagia and metrorrhagia
 Dyspareunia
 Abnormal vaginal discharge
 Dx primarily based on clinical findings.
 Tx -Empirical antibiotic therapy.
-Cefoxitin, cefotetan, doxycycline
-If signs of vaginitis → add oral metronidazole.

Bartholin’s abscess/cyst

 The Bartholin’s glands lie in the posterior vaginal wall at the introitus and secrete mucous like
fluid via a short duct into the vagina.
 They are normally the size of a pea but when the duct becomes blocked a cyst can form.
 Present acutely as an oval shaped lump, in the posterior labia may grow to the size of a golf
ball or larger; usually unilateral; cause discomfort with walking, sitting and sexual intercourse.
 When the gland is infected, most commonly with skin or genitourinary bacteria, e.g.
Staphylococcus, Escherichia coli, an abscess can develop.
o These arise more acutely than the Bartholin’s cysts and are particularly painful.
 Small asymptomatic cysts may not require treatment and abscesses can sometimes resolve
with antibiotics
 Treatment of large cysts and abscesses require surgery: The procedure, called
marsupialization, involves making a pouch like opening to the gland by incising into the cyst
wall and then suturing it to the overlying skin to ensure the new opening continues to drain
the fluid from the glands.

Vulval and vaginal trauma

 Injuries to the vulva and vagina may result in severe haemorrhage and haematoma formation.
 Vulval bruising may be particularly severe because of the rich venous plexus in the labia, and
commonly results from falling astride.
 Lacerations of the vagina are often associated with coitus.
o It is important to suture vaginal lacerations and to be certain that the injury does not
penetrate into the peritoneal cavity.
 Vulval haematomas often subside with conservative management but drainage.

Acute abdominal pain of uncertain origin

 It is vital to always exclude pregnancy and particularly ectopic pregnancy.
 Gynaecological disorders in women with a negative pregnancy test and acute pelvic pain
include PID, functional ovarian cysts, ovarian or peritoneal endometriosis and adnexal torsion.
 The most common gastrointestinal causes that can present with acute pelvic pain include:
appendicitis, acute sigmoid diverticulitis, and Crohn’s disease.
 Ovarian torsion usually occurs in the presence of an enlarged ovary.
o Women with torsion present with sudden onset of sharp unilateral pelvic pain that is
often accompanied by nausea and vomiting.
o The sonographic findings in ovarian torsion are variable; ovary is enlarged and can be
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seen in an abnormal location above or behind the uterus.
o The absence of blood flow is an important sign and a lack of venous waveform on
Doppler ultrasound has a high positive predictive value.
 presence of arterial and venous flow does not exclude torsion and any cases
where it is suspected clinically require laparoscopy to visualize the adnexae.
o If the torsion is reversed early in the process the ovary may be saved.

Acute and excessively heavy unscheduled vaginal bleeding

 Heavy uterine bleeding not associated with pregnancy that is of sufficient volume to require
urgent or emergent medical intervention.
 Women presenting with acute bleeding most often have ovulatory dysfunction but may also
have an underlying coagulopathy.
 The management of acute AUB/HMB can require dilatation and curettage but can be usually
managed non-surgically with the administration of gonadal hormones, and/or intrauterine
tamponade.

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Topic 13: Infertility: classification, causes, history and investigations (pp 265- 272)

 Primary infertility is defined as infertility without a previous pregnancy or live birth

 secondary infertility is the failure to conceive after one or more pregnancies, whether
successful or ending in miscarriage, ectopic pregnancy or voluntary termination.
 Improved methods for investigation of infertility frequently reveal a problem in both partners,
leading to the concept of relative subfertility.
 If conception does not occur after 12 months of regular sexual intercourse then the couple
should be considered to be potentially infertile, as 80% of couples normally conceive within 1y

History and Examination

 The initial consultation should involve both partners.
 Basic investigations, including baseline blood tests for both partners, and semen analysis, can
be organized through the General Practice with results available at the initial meeting.
 The history should include the following:
o Age, occupation and educational background of both partners.
o Number of years that conception has been attempted and the previous history of
contraception.
o Previous conceptions of either partner in this or previous relationships.
o Details of any complications associated with previous pregnancies, deliveries and
postpartum.
o Full gynaecological history including regularity, frequency and nature of menses,
cervical smears, intermenstrual bleeding and vaginal discharge.
o Coital history, including frequency of intercourse, dyspareunia, post-coital bleeding,
erectile or ejaculatory dysfunction
o History of sexually transmitted diseases and their treatment.
o A general medical history to include concurrent or previous serious illness or surgery,
particularly in relation to appendicitis in the female or herniorrhaphy in the male; a
history of undescended testes or of orchidopexy.
 Azoospermic men should be examined for congenital bilateral absence of the vas deferens
(CBAVD) which is associated with cystic fibrosis mutations.

Female Infertility
 General factors such as age, serious systemic illness, inadequate nutrition, excessive exercise
and emotional stress may all contribute to female infertility.
 The majority of cases of female infertility follow from disorders of tubal or uterine anatomy or
function, or ovarian dysfunction leading to anovulation. Less frequently observed disorders
include cervical mucus ‘hostility’, endometriosis and dyspareunia.
 Disorders of ovulation Disorders of ovulation are divided into four categories, defined by the
World Health Organization (WHO):
o Type I – hypogonadal hypogonadism resulting from failure of pulsatile gonadotrophin
secretion from the pituitary. This relatively rare condition can be congenital (as in
Kallman’s syndrome) or acquired.
 Serum concentrations of LH, FSH and oestradiol are abnormally
low/undetectable and menses will be absent or very infrequent.
o Type II – normogonadotropic anovulation, most commonly caused by PCOS.
 serum concentrations of FSH will be normal and LH normal or raised; Serum
anti-Mullerian hormone (AMH) will be elevated and there may also be
elevation of serum testosterone or free androgen index.
o Type III – hypergonadotropic hypogonadism, frequently described as ‘premature
ovarian failure’ describes cessation of ovulation due to depletion of the ovarian
follicle pool before age 40 years.
 Serum gonadotrophin concentrations will be greatly raised and AMH
low/undetectable, with postmenopausal (low) concentrations of oestradiol
o Type IV – hyperprolactinaemia, with elevated serum prolactin and low/normal
serum FH and LH. Frequently due to a pituitary microadenoma.

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 Anovulation is usually associated with amenorrhoea or oligomenorrhoea. Alterations in the

menstrual cycle are commonly associated with periods of stress and also with excessive
weight gain or obesity, worsening the impact of PCOS on ovulation, or at the other extreme,
with anorexia nervosa or excessive exercise leading to hypogonadal (type I) anovulation.

Tubal factors
 The Fallopian tube first collect the ovum from its site of ovulation from the ruptured Graafian
follicle and then transport the ovum to the ampullary segment, where fertilization occurs.
 The fertilized ovum must then be transported to the uterine cavity to arrive at the correct
point in the menstrual cycle at which the endometrium becomes receptive to implantation
 Tubal factors account for about 10–30% of cases of infertility; Occasionally, congenital
anomalies occur but the commonest cause of tubal damage is infection.
o Infection may cause occlusion of the fimbrial end of the tube, with the collection of
fluid (hydrosalpinx) or pus (pyosalpinx) within the tubal lumen.
o The commonest cause of acute salpingitis is with Chlamydia trachomatis; other
organisms such as Neisseria gonorrhoeae, Escherichia coli, haemolytic streptococci.
o Disorders such as appendicitis associated with peritonitis or inflammatory conditions
including Crohn’s disease or ulcerative colitis can result in peritubal and peri-ovarian
adhesions, leaving the internal structure of the Fallopian tube relatively unaffected.
Uterine factors
 Implantation is less likely to occur if there is distortion of the uterine cavity due to submucous
fibroids or congenital abnormalities such as an intrauterine septum.
 These disorders are often amenable to surgical correction.
 Subserous or entirely intramural fibroids do not appear to affect implantation.
 Intrauterine adhesions or synechiae following over-vigorous curettage or infection
(Asherman’s syndrome) result in inadequate endometrial development, absent or light
periods and recurrent implantation failure.

Endometriosis
 Severe disease with large ovarian cysts and extensive adhesions distorting tubal anatomy is
likely to lead to subfertility due to impairment of ovulation and entrapment of the oocyte by
the Fallopian tube.
 Milder forms have also been linked to subfertility and surgical treatment of grade I and II
endometriosis led to improvement in spontaneous pregnancy and live birth.

Cervical factors
 At the time of ovulation, endocervical cells secrete copious, clear, watery mucus, with high
water content and elongated glycoprotein molecules containing channels that facilitate
passage of spermatozoa into the uterine cavity.
 After ovulation, mucus produced by the cervix under the influence of progesterone is hostile
to sperm penetration.
 Cervical infection or antisperm antibodies in cervical mucus or seminal plasma, can inhibit
sperm penetration and result in subfertility.

Investigation of Infertility
 Detection of ovulation
o The assessment of ovulation depends on the menstrual history. In the presence of a
regular menstrual cycle ovulatory status can be investigated by changes in basal body
temperature, cervical mucus or hormone levels, by endometrial biopsy or by US.
 Ovulation can be inferred by detection of the LH surge in blood or urine,
with a peak that occurs approximately 24 hours before ovulation.
 Formation of the corpus luteum can be demonstrated by measurement of
serum progesterone in the luteal phase of the cycle.
o Transvaginal US of the ovaries can be used to track follicle growth; diameter
increases from 11.5 mm 5 days before ovulation to 20 mm on the day before
ovulation and decreases to approximately half this size on the day after ovulation.

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o Investigation of anovulation If there is evidence of anovulation, then further

investigation should include measurement of:
 Serum FSH, LH and oestradiol on day 2 or 3 of a natural or induced
menstruation, along with measurement of AMH.
 Serum prolactin and thyroid function.
 MRI or CT of the sella turcica if prolactin levels are raised.
o Assessment of ovarian reserve
 Ovarian reserve testing using measurement of AMH in serum and/or antral
follicle count (AFC) with transvaginal US allows an individual estimate of
‘ovarian reserve’ to be made.
 An age-related low AMH or low AFC predicts poor oocyte yield at IVF and a
lower than average chance of pregnancy, whereas higher than average
values predict a better ovarian response to gonadotrophin stimulation.
 Helpful in identifying predicted oocyte quantity after stimulation, but dont
identify oocyte quality with the same precision.
 Investigation of tubal patency
o Tubal patency need not be established if the couple are to proceed directly to IVF.
o Uterine anatomy should then be checked with high-resolution transvaginal
ultrasound or hysterosalpingography (HSG).
 A radio-opaque contrast medium is injected into the uterine cavity and
Fallopian tubes; The contrast medium outlines the uterine cavity and will
demonstrate any filling defects.
 It will also show whether there is evidence of tubal obstruction and the site
of the obstruction.
 HSG should be performed within the first 10 days of the menstrual cycle to
avoid inadvertent irradiation of a newly fertilized embryo.
 Laparoscopy and dye insufflation enables direct visualization of the pelvic
organs and allows assessment of pelvic pathologies such as endometriosis
or adhesions.
- Laparoscopy can be combined with hysteroscopy to assess the
uterine cavity. A ‘see-and-treat’ policy.
Investigation of the male partner
 The most useful investigation of the male partner is by semen analysis; Semen should be
collected by masturbation into a sterile container after 3 days abstinence and examined
within 2 hours of collection.
 The major features of the semen analysis are:
o Volume: 80% of fertile males ejaculate between 1 mL and 4 mL of semen.
 Low volumes may indicate androgen deficiency and high volumes abnormal
accessory gland function.
o Sperm concentration: The absence of all sperm (azoospermia) indicates sterility,
although sperm may well be recoverable by percutaneous epididymal aspiration
(PESA) or testicular aspiration (TESA) or testicular biopsy.
o A normal analysis should show good motility in 60% of sperm within 1 hour of
collection. The characteristic of forward progression is equally important. The World
Health Organization grades sperm motility according to the following criteria:
 grade 1 – rapid and linear progressive motility
 grade 2 – slow or sluggish linear or non-linear motility
 grade 3 – non-progressive motility
 grade 4 – immotile.
o Sperm morphology shows great variability even in normal fertile males, and is less
predictive of subfertility than count or motility. It is important tolook for leukocytes
as they may indicate the presence of infection.
 Spermatogenesis and sperm function may be affected by a wide range of toxins and
therapeutic agents; Chemotherapeutic agents, particularly alkylating agents, depress sperm
function and sulphasalazine, frequently used to treat Crohn’s disease, reduces sperm motility
and density.

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Topic 14: Treatment of infertility (pp 272- 275)

 If the history, examination and systematic investigation in both partners is normal, and the
duration of infertility is less than 18 months, the couple should be reassured and advised
regarding coital frequency and simple lifestyle changes that may improve chances of
conception.
 Both partners should be advised to stop smoking and limit their intake of alcohol.
 Women or men with a body mass index of more than 30 should be encouraged to join a
supervised programme of weight loss.

Anovulation
 In the presence of WHO group II anovulation with stigmata of PCOS, normal FSH and prolactin
levels, the drug of choice remains clomiphene citrate.
o Clomiphene will produce ovulation in 80% of subjects leading to pregnancy in about
one half of those who ovulate.
o Clomiphene is administered from day 2-6 of the cycle with an initial dosage of 50
mg/day, increased to 100 and 150 mg/ day where necessary.
o US monitoring of follicle growth is recommended, with abstention from intercourse if
there are more than two mature follicles, to reduce the incidence of multiple
pregnancy.
o More recently, the aromatase inhibitor letrozole has been used as an oral alternative
to clomiphene, with an increase in percentage of women who ovulate and possibly
better pregnancy rates.
 Second-line management of anovulation may involve laparoscopic ovarian diathermy (LOD),
which induces ovulation in over 70% of PCOS patients.
o LOD has the advantage of inducing natural mono-ovulation allowing a drug-free and
more natural conception.
o Alternatively, ovulation may be induced with daily injection of recombinant or
urinary derived FSH although this may be costly and monitoring with ultrasound and
blood tests is required due to the possibility of over response and risk of multiple
pregnancy.
 Anovulation associated with hyperprolactinaemia, in the absence of macroadenoma, can be
treated with a dopamine receptor agonist such as cabergoline.

Tubal pathology
 Tubal microsurgery has been almost completely supplanted by IVF in the management of
tubal infertility.
 Laparoscopic surgery may still be necessary to perform salpingectomy or tubal clipping prior
to IVF in the presence of hydrosalpynx (refers to a fallopian tube that's blocked with a
watery fluid).
 At times the blocked tubal end can be opened, i.e. salpingostomy.
 There is an increased risk of ectopic pregnancy after all forms of tubal surgery.

Intrauterine insemination (IUI)

 Placement of a sample of sperm into the uterine cavity using a soft, flexible catheter has been
performed for many years.
 The technique has been enhanced by preparation of the semen sample by washing and
isolation of motile sperm, and by stimulation of ovulation using low dose gonadotrophins.
 IUI is a specific treatment for coital dysfunction and for abnormalities of cervical mucus but is
also used frequently to treat unexplained infertility and mild male factor infertility.
 IUI requires healthy, patent Fallopian tubes.

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In vitro fertilization and embryo transfer

 IVF involves stimulation of multiple ovarian follicle development using recombinant or urinary
derived gonadotrophins, with concurrent use of GnRH agonist or antagonist to prevent a
premature LH surge and ovulation before oocytes are harvested.
 Oocytes are collected using transvaginal ultrasound guided needle follicle aspiration, with the
oocytes being isolated from the follicular fluid and cultured in the presence of a washed
sample of the partner’s sperm.
 Fertilized oocytes (embryos) can be cultured for up to 5 days, at which point they reach the
blastocyst stage of division and it becomes possible to make a detailed assessment of their
morphological quality.
 The ‘best’ one or two blastocysts are then transferred to the uterine cavity using a simple
catheter, with remaining blastocysts being cryopreserved for use later if conception does not
follow the fresh embryo transfer.
 Female age remains the main determinant of outcome and an increasing number of women
are resorting to treatment with donated oocytes from younger women.
 The most frequent cause of obstetric and paediatric problems in offspring from IVF is the
result of multiple pregnancy leading to premature birth.

Ovarian Hyperstimulation Syndrome (OHSS)

 OHSS is the consequence of over dosing with gonadotrophins leading to excessive follicle
development and high circulating concentrations of oestrogens and vascular endothelial
growth factor (VEGF).
 OHSS is potentially lethal and is almost completely avoidable if a conservative approach to
ovarian stimulation is used.
 In its severe form, the condition results in marked ovarian enlargement with fluid shift from
the intravascular compartment into the third space, leading to ascites, pleural effusion,
sodium retention and oliguria.
 Patients may become hypovolaemic and hypotensive and may develop renal failure as well as
thromboembolic phenomena and adult respiratory distress syndrome.
 The pathophysiology of this condition appears to be associated with an increase in capillary
vascular permeability.
 Treatment: If the haematocrit is below 45% and the signs and symptoms are mild, the patient
can be managed at home, but where there is significant ascites as judged by ultrasound
examination, she should be hospitalized.
o Baseline electrolyte values and liver and kidney function should be assessed.
o Volume expansion can be performed using human albumin, sometimes with
crystalloid, and, if there is severe ascites or pleural effusion.
o Fluid should be drained to reduce the fluid load.
o Drugs such as indomethacin and ACE-I may be useful in reducing the severity.
 Eventually, the cysts will undergo resorption, and the ovaries will return to their normal size.

Treatment of Male Infertility

 Specific treatment is possible in only a small proportion of infertile males.
 Testicular size is important and with the finding of small testes, azoospermia, high FSH and
low AMH levels, it is unlikely that any therapy will help.
 Where FSH levels are normal and testicular size is normal, ductal obstruction should be
suspected and testicular biopsy performed.
 If normal spermatogenesis is demonstrated, then it is necessary to proceed to vasography and
exploration of the scrotum.
 Surgical anastomosis may re-establish fertility.
 Gonadotrophins are effective in the rare cases of men with hypogonadotrophic
hypogonadism, and dopamine agonists are used in men with hyperprolactinaemia.
 The most successful treatment for male infertility is ICSI: involves the direct injection of a
single immobilized sperm into the cytoplasm of the oocyte.
 Donor insemination. By using a sperm donation in the insemination.

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Topic 15: Bleeding in early pregnancy (pp 277- 282)

Bleeding in Early Pregnancy

 Vaginal bleeding occurs in up to 25% of pregnancies prior to 20 weeks.
 It is a major cause of anxiety for all women, especially those who have experienced previous
pregnancy loss, and may be the presenting symptom of life-threatening conditions such as
ectopic pregnancy.
 Bleeding should always be considered as abnormal in pregnancy and investigated
appropriately.
 A small amount of bleeding may occur as the blastocyst implants in the endometrium 5–7
days after fertilization (implantation bleed). If this occurs at the time of expected
menstruation it may be confused with a period and so effect calculations of gestational age
based on the last menstrual period.
 The common causes for bleeding in early pregnancy are miscarriage, ectopic pregnancy and
benign lesions in the lower genital tract. Less commonly it may be the presenting symptom of
hydatiform mole or cervical malignancy.

Miscarriage
 The medical term for pregnancy loss less than 24 weeks gestation is ‘miscarriage’.
 Other term is pregnancy loss before fetal viability or a fetal weight of less than 500 g.
 Most miscarriages occur in the second or third month; a much higher proportion of
pregnancies miscarry at an early stage if the diagnosis is based on the presence of a significant
plasma level of beta-hCG.
The etiology of miscarriage
 Genetic abnormalities
o Chromosomal abnormalities are a common cause of early miscarriage and may result
in failure of development of the embryo with formation of a gestation sac without
the development of an embryo or with later expulsion of an abnormal fetus.
o The most common chromosomal defects are autosomal trisomies, which account for
half the abnormalities.
 Endocrine factors
o Progesterone is essential for the maintenance of a pregnancy, and early failure of the
corpus luteum may lead to miscarriage.
o The prevalence of PCOS is significantly higher in women with recurrent miscarriage
than in the general population.
o Women with poorly controlled diabetes and untreated thyroid disease are at higher
risk of miscarriage and fetal malformation.
 Maternal illness and infection
o Severe maternal febrile illnesses associated with infections, such as influenza,
malaria, predispose to miscarriage; the presence of bacterial vaginosis has been
reported as a risk factor for preterm delivery and second, but not first trimester,
miscarriage. Other severe illnesses involving the cardiovascular, hepatic and renal
systems may also result in miscarriage.
 Maternal lifestyle and drug history
o Antidepressant use and periconceptual NSAIDs have been associated with
miscarriage.
o Smoking, alcohol (more than 5 units a week), caffeine (more than 3 cups per day),
cocaine and cannabis use increase the risk of miscarriage.
o There is some evidence that stress may also be associated with pregnancy loss.
 Abnormalities of the uterus
o Congenital abnormalities of the uterine cavity, such as a bicornuate uterus or
subseptate uterus, may result in miscarriage.
o Uterine anomalies can be demonstrated in 15-30% of women experiencing recurrent
miscarriages. The fetal survival rate is 86% where the uterus is septate and worst
where the uterus is unicornuate.

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 Cervical incompetence
o Cervical incompetence clinically results in second trimester miscarriage or early
preterm delivery.
o The miscarriage tends to be rapid, painless and bloodless.
o The diagnosis is established by the passage of a Hegar 8 dilator without difficulty in
the non-pregnant woman or by ultrasound examination.
o May be congenital, but most commonly results from physical damage caused by
mechanical dilatation of the cervix or by damage inflicted during childbirth.
 Autoimmune factors
o Antiphospholipid antibodies – lupus anticoagulant (LA) and anticardiolipin antibodies
(aCL) – are present in 15% of women with recurrent miscarriage.
o Pregnancy loss is thought to be due to thrombosis of the uteroplacental vasculature
and impaired trophoblast function.
o In addition to miscarriage there is an increased risk of intrauterine growth restriction,
pre-eclampsia and venous thrombosis.
 Thrombophilic defects
o Defects in the natural inhibitors of coagulation – antithrombin III, protein C and
protein S – are more common in women with recurrent miscarriage.
o The majority of cases of activated protein C deficiency are secondary to a mutation in
the factor V (Leiden) gene.
Clinical types of miscarriage
 Threatened miscarriage
o The first sign of an impending miscarriage is the development of vaginal bleeding in
early pregnancy; uterus is found to be enlarged and the cervical os is closed.
o Lower abdominal pain is either minimal or absent.
o Most women presenting with a threatened miscarriage will continue with the
pregnancy irrespective of the method of management.
 Inevitable/incomplete miscarriage
o Patient develops abdominal pain usually associated with increasing vaginal bleeding.
o The cervix opens, and eventually products of conception are passed into the vagina.
 If some of the products of conception are retained, then the miscarriage
remains incomplete
 Complete miscarriage
o An incomplete miscarriage may proceed to completion spontaneously, when the
pain will cease and vaginal bleeding will subside with involution of the uterus.
o Spontaneous completion of a miscarriage is more likely in miscarriages over 16
weeks gestation than in those between 8 and 16 weeks gestation, when retention of
placental fragments is common.
 Miscarriage with infection (sepsis)
o During the process of miscarriage or after therapeutic termination of a pregnancy –
infection may be introduced into the uterine cavity.
o The clinical findings of septic miscarriage are similar to those of incomplete
miscarriage with the addition of uterine and adnexal tenderness.
o The vaginal loss may become purulent and the patient pyrexial.
o In cases of severe overwhelming sepsis, endotoxic shock may develop with profound
and sometimes fatal hypotension.
o Other manifestations include renal failure, disseminated intravascular coagulopathy
and multiple petechial haemorrhages.
o Organisms which commonly invade the uterine cavity are Escherichia coli,
Streptococcus faecalis, Staphylococcus albus and S. aureus, Klebsiella, Clostridium
welchii and C. perfringens.
 Missed miscarriage (empty gestation sac, embryonic loss, early and late fetal loss)
o In empty gestation sac (anembryonic pregnancy or blighted ovum) a gestational sac
of ≥25 mm is seen on ultrasound, but there is no evidence of an embryonic pole or
yolk sac or change in size of the sac on rescan 7 days later.

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o Embryonic loss is diagnosed where there is an embryo ≥7 mm in size without cardiac

activity or where there is no change in the size of the embryo after 7 days on scan.
 Spontaneous second trimester loss
o Pregnancy loss occurs between 12 and 24 weeks associated with spontaneous
rupture of membranes or cervical dilatation despite the presence of fetal heart
activity.
 Recurrent miscarriage
o Recurrent miscarriage is defined as three or more successive pregnancy losses prior
to viability.
o The problem affects 1% of all women, approximately three times the number that
would be expected by chance alone.
o It is important to remember that after two consecutive miscarriages the likelihood of
a successful third pregnancy is still around 80%; Even after three consecutive
miscarriages, there is still a 55–75% chance of success recurrent miscarriage is
unlikely to be a random event and that it is necessary to seek a cause.
Management
 Examination of the patient should include gentle vaginal and speculum examination to
ascertain cervical dilatation.
o If there is pyrexia, a high vaginal swab should be taken for bacteriological culture.
 An ultrasound scan is valuable in deciding if the fetus is alive and normal.
o One effect of the routine use of scans in early pregnancy is that the diagnosis of
miscarriage may be established before there is any indication that the pregnancy is
abnormal.
o It is sometimes preferable to repeat the scan a week later than proceed to
immediate medical or surgical uterine evacuation, to enable the mother to come to
terms with the diagnosis.
 Miscarriage may be complicated by haemorrhage and severe pain, and may necessitate blood
transfusion and relief of pain with opiates.
 If there is evidence of infection, antibiotic therapy should be started immediately and
adjusted subsequently if the organism identified in culture is not sensitive to the prescribed
antibiotic.
 Septic miscarriage complicated by endotoxic shock is treated by massive antibiotic therapy
and adequate, carefully controlled fluid replacement.
o If there is evidence of ‘cervical shock’, any products of conception protruding
through the cervical os should be removed by grasping with tissue holding forceps.
 Non-sensitized Rhesus (Rh) negative women should receive anti-D immunoglobulin for
miscarriages over 12 weeks of gestation (including threatened) and all miscarriages where the
uterus is evacuated (whether medically or surgically).
Surgical management
 Surgical evacuation of retained products of conception involves dilatation of the cervix and
suction curettage to remove the products.
 This is the modality of choice when there is heavy bleeding or persistent bleeding if the vital
signs are unstable or in the presence of infected retained tissue.
 Intrauterine infection may result in tubal infection/obstruction with subsequent infertility.
 If uterine perforation is suspected and there is evidence of intraperitoneal haemorrhage or
damage to the bowel, then a laparoscopy or laparotomy should be performed.
Medical management
 When the uterine contents have not begun to be expelled naturally, the process can be
expedited by the use of a prostaglandin analogue such as misoprostol or dinoprostone with or
without the antiprogesterone mifepristone.
 Passage of the products will normally be accomplished in approximately 48–72 hours, but
bleeding may continue for up to 3 weeks.
Conservative Management
 This is the favoured option for incomplete miscarriages when the uterus is small, or on scan,
there is minimal evidence of retained products; as well as women with missed miscarriages
who do not wish to undergo either of the former options.

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 Success rates depend on similar factors to those for medical management but patients should
be warned that it may take several weeks before complete miscarriage.

Recurrent miscarriage
 Recurrent miscarriage should be investigated by examining the karyotype of both parents and,
if possible any fetal products.
o Those with karyotypic abnormalities should be referred to a clinical geneticist.
 Maternal blood should be examined for lupus anticoagulant and anticardiolipin antibodies on
at least two occasions 6 weeks apart.
o Women with persistent lupus anticoagulant and anticardiolipin antibodies can be
treated with low dose aspirin and heparin during subsequent pregnancies
 An ultrasound scan should be arranged to assess ovarian morphology for PCOS and the
uterine cavity.
 Cervical cerclage carried out at 14-16 weeks in cases of cervical incompetence reduces the
incidence of preterm delivery, but has not been shown to improve fetal survival.
 An alternative approach to the use of prophylactic cerclage is serial ultrasound measurement
of the length of the cervical canal with treatment only if this drops below 25 mm.
 There is increasing evidence that progesterone (which has anti-inflammatory properties) is
effective in prolonging high risk pregnancies.
 Bacterial vaginosis has been associated with second trimester losses and preterm delivery
o Treatment of this condition with clindamycin (not metronidazole) does appear to
reduce the risk of preterm delivery, but there is no evidence to support empirical
antibiotic use in women with second trimester loss or for other infections.

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Topic 16: Ectopic pregnancy (pp 282- 286)

The term ‘ectopic pregnancy’ refers to any pregnancy occurring outside the uterine cavity.
The most common site of extrauterine implantation is the Fallopian tube, but it may occur in the ovary,
abdomen, or in the cervical canal

Predisposing factors
 The majority of cases of ectopic pregnancy have no identifiable predisposing factor.
 Factors that increase the risk are:
o previous history of ectopic pregnancy
o sterilization
o pelvic inflammatory disease (PID)
o subfertility
 The increased risk for an intrauterine device (IUD)
applies only to pregnancies that occur despite the
presence of the IUD.

Clinical presentation
 Acute presentation
o The classical pattern of symptoms includes amenorrhoea, lower abdominal pain
which precedes uterine bleeding.
o Subdiaphragmatic irritation by blood produces referred shoulder tip pain and
syncopal episodes may occur.
o The period of amenorrhoea is usually 6-8 weeks, but may be longer if implantation
occurs in the interstitial portion of the tube or in abdominal pregnancy.
o Clinical examination reveals a shocked woman with hypotension, tachycardia and
signs of peritonism including abdominal distension, guarding and rebound
tenderness.
o Pelvic examination is usually unimportant because of the acute pain and discomfort,
and should be undertaken with caution.
 Subacute presentation
o After a short period of amenorrhoea, the patient experiences recurrent attacks of
vaginal bleeding and abdominal pain.
o Any woman who develops lower abdominal pain following an interval of
amenorrhoea should be considered as a possible ectopic pregnancy.
o In its subacute phase, it may be possible to feel a mass in one fornix.
Pathology
 Implantation of the conceptus in the tube results in hormonal changes that mimic normal
pregnancy; The uterus enlarges and the endometrium undergoes decidual change.
 Implantation within the fimbrial end or ampulla of the tube allows greater expansion before
rupture occurs, whereas implantation in the interstitial portion or the isthmic part of the tube
presents with early signs of haemorrhage or pain.
 Expulsion of the embryo into the peritoneal cavity or partial miscarriage may also occur with
continuing episodes of bleeding from the tube.
Diagnosis
 Whilst the diagnosis of the acute ectopic pregnancy rarely presents a problem, diagnosis in
the subacute phase may be much more difficult.
o It may be mistaken for a threatened or incomplete miscarriage, acute salpingitis,
appendicitis with pelvic peritonitis or rupture or haemorrhage of an ovarian cyst.
 If sufficient blood loss has occurred into the peritoneal cavity, the haemoglobin level will be
low and the white cell count will be usually normal or slightly raised.
 Serum hCG measurement will exclude ectopic pregnancy if negative with a specificity of
greater than 99%.
 In the presence of a viable intrauterine pregnancy, the serum hCG will double over a 48 hour
period.

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 A normal intrauterine pregnancy will usually be visualized on scan where the serum hCG level
is more than 1000 iu/L.
 Intrauterine pregnancy can usually be identified by transabdominal scan at 6 weeks gestation
and somewhat sooner by transvaginal scan at 5-6 weeks gestation.

Management
 In patients who are haemodynamically compromised, blood should be taken for urgent cross
matching and transfusion.
 Laparotomy should be performed as soon as possible with removal of the damaged tube.
 Non-sensitized Rh negative women should receive anti-D immunoglobulin in any ectopic
pregnancy regardless of the mode of treatment.
 Once the diagnosis is confirmed, the options for surgical treatment are:
o Salpingectomy: If the tube is badly damaged, or the contralateral tube appears
healthy, the correct treatment is removal of the affected tube.
o Salpingotomy: Where the ectopic pregnancy is contained within the tube, it may be
possible to conserve the tube by removing the pregnancy and reconstituting the
tube.
 Administration of methotrexate, either systemically or by injection into the ectopic pregnancy
by laparoscopic visualization or by ultrasound guidance.
o It is most effective where the ectopic is less than 2 cm in size and the hCG less than
1500 iu/L.

Pregnancy of unknown location

 This is defined as a positive pregnancy test where there are no signs on ultrasound of either
an intrauterine or ectopic pregnancy, or retained products of conception and occurs in 10% or
pregnancies.
 This may represent an intrauterine pregnancy that is too small to see on ultrasound but
requires follow up to exclude ectopic pregnancy.
 Conservative management with serial hCG measurement and repeat ultrasound is safe for
asymptomatic women.
 A serum progesterone level of less than 20 nmol/L is predictive of pregnancy failure but does
not help in predicting pregnancy location.

Management of other forms of extrauterine pregnancy

 Abdominal pregnancy
o Abdominal pregnancy presents a life-threatening hazard to the mother.
o The placenta implants outside the uterus and across the bowel and pelvic
peritoneum
o Any attempt to remove it will result in massive haemorrhage that is extremely
difficult to control.
o The fetus should be removed by laparotomy and the placenta left in situ to reabsorb
or extrude spontaneously.
 Cervical pregnancy
o Cervical pregnancy often presents as the cervical stage of a spontaneous miscarriage.
o Occasionally, it is possible to remove the conceptus by curettage but haemorrhage
can be severe, and in 50% of cases it is necessary to proceed to hysterectomy to
obtain adequate haemostasis.

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Topic 17: Trophoblastic disease (pp 286- 287)

 Abnormality of early trophoblast may arise as a developmental anomaly of placental tissue,

and results in the formation of a mass of edematous and avascular villi.
 There is usually no fetus but the condition can be found in the presence of a fetus.
 The placenta is replaced by a mass of grapelike vesicles known as a hydatidiform mole.
 Invasion of the myometrium without systemic spread occurs in some of cases of benign mole,
and is known as invasive mole or chorioadenoma destruens; malignant change may occurs and
known as choriocarcinoma.

Pathology
 Molar pregnancy is thought to arise from fertilization by two sperm, and can be diploid with
no female genetic material (complete mole) or it may exhibit triploidy (partial mole).
 Benign mole remains confined to the uterine cavity and decidua.
 The histopathology exhibits a villous pattern, which is also found in the invasive.
o invasive molar tissue penetrates the myometrium deeply and may result in serious
haemorrhage.
 Metastases via blood may occur locally in the vagina but most commonly appear in the lungs.
 Theca lutein cysts occur in about one-third of all cases as a result of high circulating levels of
hCG; regress spontaneously with removal of the molar tissue.

Clinical presentation
 Vaginal bleeding in the first half of pregnancy, and spontaneous miscarriage often
occurs at about 20 weeks gestation.
 Occasionally, the passage of a grape-like villus heralds the presence of a mole.
 The uterus is larger than normal, but this is not a reliable sign as it may sometimes be small.
 Severe hyperemesis, pre-eclampsia and unexplained anaemia are suggestive of the disorder.
 Diagnosis can be confirmed by ultrasound scan and by the presence of very high levels of
hCG in the blood or urine.
 It must be remembered that choriocarcinoma sometimes can occur following a miscarriage or
a normal term intrauterine pregnancy.

Management
 Pregnancy is terminated by suction curettage.
 Adequate replacement of blood loss is essential.
 Serial estimations of hCG are followed for a period of 6m or 2yrs, initially every 2wks.
o If hCG levels reach normal within 8 weeks of evacuation of the mole follow-up will be
for 6 months, otherwise follow-up will be for 2 years but in the second samples are
collected at intervals of 3 months.
 If the histological evidence shows malignant change, chemotherapy with methotrexate and
actinomycin D is employed and produces good results.
 Pregnancy is contraindicated until 6 months after the serum hCG levels fall to normal.
 Oestrogen-containing oral contraceptives and HRT can be used as soon as hCG levels are
normal.
 The risk recurrence in subsequent pregnancies is 1 in 74 and serum hCG levels should be
checked 6 weeks after any subsequent pregnancy.

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Topic 18: Vomiting in early pregnancy (pp 287- 290)

 Nausea and vomiting are common symptoms in early pregnancy usually starting between 4-10
weeks gestation, and resolving before 20 weeks.
 Symptoms persist beyond 20 weeks few cases but new symptoms appearing after the 12th
week should not be attributed to hyperemesis.
 Hyperemesis gravidarum is persistent pregnancy-related vomiting associated with weight loss
of more than 5% of body mass and ketosis.
o Associated with dehydration, electrolyte imbalance and thiamine deficiency.
Etiology
 The etiology of hyperemesis is uncertain, with multifactorial causes such as endocrine,
gastrointestinal and psychological factors proposed.
 Hyperemesis occurs more often in multiple pregnancy and hydatidiform mole, suggesting an
association with the level of hCG.
 Women with a previous history of hyperemesis are likely to experience it in subsequent
pregnancies.

Diagnosis
 Ask about the frequency of vomiting, trigger factors and whether any other members of the
family have been affected.
 A history of vomiting in a previous pregnancy or outside pregnancy should be sought.
 Smoking and alcohol can both exacerbate symptoms.
 If this pregnancy resulted from fertility treatment or there is a close family history of twins, a
multiple pregnancy is more likely.
 Early pregnancy bleeding or a past history of trophoblastic disease may point to a
hydatidiform mole.
 Clinical features of dehydration include tachycardia, hypotension and loss of skin turgor.
 A dipstick analysis of the urine for ketones, blood or protein should be performed.
 Urine should be sent for culture to exclude infection and an ultrasound arranged to look for
multiple pregnancy or gestational trophoblastic disease.

Management
 If the vomiting is mild to moderate and not causing signs of dehydration, then usually
reassurance and advice will be all that is necessary.
 Simple measures include:
o Taking small, carbohydrate meals and avoiding fatty foods.
o Powdered ginger root or pyridoxine (vitamin B6).
o Avoiding large volume drinks, especially milk and carbonated drinks.
o Raising the head of the bed if reflux is a problem.
 A history of persistent, severe vomiting with evidence of dehydration requires admission to
hospital for assessment and management of symptoms.
 Thromboprophylaxis with compression stockings and low-molecular weight heparin should be
considered.
 Anti-emetic therapy is reserved for those women who do not settle on supportive measures,
or who persistently relapse.
o Currently antihistamines are the recommended pharmacological for first-line
treatment for nausea and vomiting, no anti-emetic being approved for treatment.
 Vitamin supplements including thiamine should be given, particularly where hyperemesis has
been prolonged.
 If hyperemesis is left untreated the mother’s condition worsens; Wernicke’s encephalopathy
is a complication associated with a lack of vitamin B1 (thiamine).
 Coma and death have been reported because of hepatic and renal involvement.
 Termination of pregnancy may reverse the condition and has a place in preventing maternal
mortality.
 Hyperemesis persisting into the third trimester should be further investigated as it may be
symptomatic of serious illness such as acute fatty liver of pregnancy.

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Topic 19: Contraception (pp 291- 303)

It’s a really huge chapter, a shortcut to my opinion is just to read AMBOSS
https://www.amboss.com/us/knowledge/Hormonal_contraceptives
https://www.amboss.com/us/knowledge/Nonhormonal_contraception

 Artificial methods of contraception act predominantly by the following pathways:

o inhibition of ovulation
o prevention of implantation of the fertilized ovum
o barrier methods of contraception, whereby the spermatozoa are physically
prevented from gaining access to the cervix.
 The effectiveness of any method of contraception is measured by the number of unwanted
pregnancies that occur during 100 women years of exposure, i.e. during 1 year in 100 women
who are normally fertile and are having regular coitus. This is known as the ‘Pearl index’.

Barrier methods of contraception

These techniques involve a physical barrier that reduces the likelihood of spermatozoa reaching the
female upper genital tract.; Barrier methods also offer protection against sexually transmitted
infection.
 Male condoms
o The basic condom consists of a thin, stretchable latex film, which is moulded into a
sheath, lubricated and packed in a foil wrapper; A teat end to collect the ejaculate.
o They have an efficiency of 97–98% with careful use, although typical failure rates can
be as high as 15 pregnancies per 100 women years.
 Female condoms
o Less widely used than the male equivalent, but have a similar failure rate and give
similar protection against infection.
o They are made of polyurethane and are suitable for a single use.
 Diaphragms and cervical caps
o The modern vaginal diaphragm consists of a thin latex rubber dome attached to a
circular metal spring. These diaphragms vary in size from 45–100 mm in diameter.
o When in the correct position the anterior edge of the ring or diaphragm should lie
behind the pubic symphysis and the lower posterior edge should lie comfortably in
the posterior fornix; it is smeared on both sides with a contraceptive cream.
 Spermicides and sponges
o Spermicides are only effective if used in conjunction with a mechanical barrier.
o Suppositories have a water-soluble or wax base and contain a spermicide.
o They must be inserted approximately 15 minutes before intercourse.
o Jellies or pastes have a water-soluble base that spreads rapidly at body temperature;
have an advantage over creams, as they spread throughout the vagina.
o Pregnancy rates vary with different agents, but avg ~9-10 per 100 women years.

Intrauterine contraceptive devices

Once inserted, they are retained without the need to take alternative contraceptive precautions. Act
mainly by preventing fertilization by reduction in the viability of ova and the number of viable sperm.
 Inert devices
o Lippes loops, Saf-T-coils and Margulis spirals are plastic or plastic-coated devices.
o They have a thread attached that protrudes through the cervix and allows the
woman to check that the device is still in place; They are not now available but may
still be found in situ in some older users.
 Pharmacologically active devices
o The addition of copper to a contraceptive device produces a direct effect on the
endometrium by interfering with endometrial oestrogen-binding sites and depressing
uptake of thymidine into DNA; Licensed for 8-13 years.
 Devices containing progestogen
o The levonorgestrel-releasing intrauterine system (Mirena®) contains 52 mg of
levonorgestrel which suppresses the normal build up of the endometrium so that, it
causes a reduction in menstrual blood loss; there is a high incidence of irregular

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scanty bleeding in the first 3 months after insertion of the device; Does not appear to
be associated with a higher risk of ectopic pregnancy; Licensed for 5 years.

 Insertion of devices
o The optimal time for insertion of the device is in the first half of the menstrual cycle.
o With postpartum women, the optimal time is 4–6 weeks after delivery.
o Insertion at the time of therapeutic abortion is safe and can be performed.
o It is unwise to insert IUDs following a miscarriage because of the risk of infection.
o Acute pain following insertion may indicate perforation of the uterus.
o The woman should be instructed to check the loop strings regularly and to notify her
doctor immediately if the strings are not palpable.

 Complications
o Perforations
 About 0.1–1% of devices perforate the uterus. If the woman notices that the
tail of the device is missing, then it must be assumed that one of the
following has occurred:
- Device has been expelled.
- Device has turned in the uterine cavity and drawn up the strings.
- Device has perforated the uterus and lies either partly or
completely in the peritoneal cavity.
o IU pregnancy
 Pregnancy rates vary according to the type of device used, from 2–6/100
women years for non-medicated IUDs and 0.5–2/100 for early generation
copper devices to less than 0.3/100 women years for third-generation
copper and levonorgestrel IUDs.
o Ectopic pregnancy
 There is a higher risk (10%) of the pregnancy being extrauterine. It is
therefore essential to think of this
 diagnosis in any woman presenting with abdominal pain and irregular
vaginal bleeding who has an IUD in situ.
o Pelvic Inflammatory Disease (PID)
 Pre-existing PID is a contraindication to this method of contraception. There
is a small increase in the risk of acute PID in IUD users, but this is largely
confined to the first 3 weeks after insertion. If PID does occur, antibiotic
therapy is commenced and, if the response is poor, the device is removed.
o Hemorrahge or Discharge
 Increased menstrual loss occurs in most women with an inert or copper IUD,
but this can be tolerated by the majority. It can be controlled by drugs such
as tranexamic acid or mefenamic acid; Intermenstrual bleeding may also
occur, but if the loss is slight it does not constitute a reason for IUD removal.
 Vaginal discharge may be due to infection but most women with an IUD
develop a slight watery or mucoid discharge.
o Pelvic pain occurs either in a chronic low-grade form or as severe dysmenorrhoea.

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Hormonal contraception
 Combined pill
o Most of the current combined pills contain 20–30 μg of ethinyl oestradiol and 150–
4000 μg of progestogen.
o The pill is usually taken for 21 days, followed by a 7-day pill-free interval during which
there is a withdrawal bleed.
o The concentration of the hormones may be the same throughout the 21 days
(monophasic preparations) or vary across the cycle (biphasic and triphasic
preparations) in order to reduce breakthrough bleeding.
o The failure rate of combined pills is 0.27–5/100 women years.
 Progestogen-only pill Contain either norethisterone or levonorgestrel and are taken daily; Because of the low d

 Mode of action of the contraceptive pills

o Combined and triphasic pills act by suppressing GnRH and gonadotrophin secretion
and suppressing the LH peak, and thus inhibiting ovulation.
o The endometrium also becomes less suitable for nidation and the cervical mucus
becomes hostile.
o Progesterone-only pills act predominantly to reduce the amount and character of the
cervical mucus, although they do alter the endometrial maturation as well.
o Ovulation is completely suppressed in only 40% of women.
 Contraindications
o The absolute contraindications: pregnancy, previous PE or DVT, sickle-cell disease,
porphyria, current active liver disease or previous cholestasis (particularly where it is
associated with a previous pregnancy), migraine associated with an aura or
carcinoma of the breast.
o Women who smoke and are also over the age of 35 years have a significantly
increased risk of coronary artery and thromboembolic disease.
 Other therapeutic uses: treatment of menorrhagia, premenstrual syndrome, endometriosis
and dysmenorrhoea.
 Major side effects
o Venous thrombosis
o Arterial disease
 both these conditions are rare in women under the age of 35 years so the
overall risk remains low.
o Small increase in the relative risk of breast and cervical cancer especially if it is
commenced before a first pregnancy.
o Gallstone formation and cholecystitis and Glucose intolerance.
o The progestogen-only pill has a higher failure rate and associated with irregular
bleeding. If it fails there is a higher risk of ectopic pregnancy.
 Beneficial effects
o Reduction in blood loss at menstruation
o a lower incidence of ectopic pregnancy
o some protection against PID and benign ovarian cysts.
o Reduced risk of both endometrial and ovarian cancer of up to 50%

Newer methods of hormonal contraception

 Effective as the combined OCP and there is good evidence that the actual hormone levels.
 The transdermal contraceptive patches are changed weekly for 3 weeks and the fourth week
is then patch free.
 For the NuvaRing®, the device is left in the vagina for 3 weeks, then removed for 1 week, then
a new vaginal ring inserted.
o The period occurs during the hormone free week.

Emergency contraception
 After unprotected intercourse, missed combined pill or a burst condom, a single 750 mg
levonorgestrel tablet is taken within 72 hours of intercourse, followed by a second dose
exactly 12 hours later.
 The levonorgestrel-only method has fewer side effects than combined.
 Side effects include mild nausea, vomiting (an additional pill should be taken if vomiting
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occurs within 2–3 hours of the first dose) and bleeding.
 The woman should be advised that:
o Her next period might be early or late.
o She needs to use barrier contraception until then.
o Return if she has any abdominal pain or if the next period is absent or abnormal.
 If the next period is more than 5 days overdue, pregnancy should be
excluded.

Non-medical methods of contraception/ Natural methods

 The rhythm method: Avoiding intercourse mid-cycle and for 6 days before ovulation and 2
days after it. Efficacy depends on being able to predict the time of ovulation.
 The ovulation method: Depends on the ability to recognize the increase in vaginal wetness
due to cervical mucus production in the phase before ovulation, and abstaining from sex
during that time and for 2 days after the peak wetness
 Coitus interruptus (withdrawal): A traditional and still widely used method of contraception
that relies on withdrawal of the penis before ejaculation. It is not a particularly reliable
method of contraception, because the best sperm often reach the tip of the penis before the
male experiences the imminent ejaculation, or he forgets in the ‘heat’ of the moment.
 Lactational amenorrhoea method: Breastfeeding has historically been the most important
means of family ‘spacing’. Ovulation resumes on average 4-6 months later in women who
continue to breastfeed. During the first 6 months after birth this is an effective method of
contraception in mothers providing they are fully breastfeeding, not giving the baby any non-
breast milk or other food, AND have remained amenorrhoeic, with failure rates as low as
1/100 women being seen.
Sterilization
 Women should be advised to continue to use other contraception until the period occurs
following the sterilization procedure.
 Men should be advised to use alternative contraception until they have had two consecutive
semen analyses showing azoospermia 2–4 weeks apart, with these analyses not done until at
least 10 ejaculations have occurred.
 The operation can be performed at any time in the menstrual cycle, but is best done in the
follicular phase of the cycle.
 Techniques
Female sterilization: Most procedures involves interruption of the Fallopian tubes but may
vary from the application of clips on the tubes to total hysterectomy.
o Laparoscopic sterilization: substantially reduced the duration of hospital stay. This is
the method of choice in most developed countries.
o Tubal clips. This is the most widely used method. The clips are made of plastic and
inert metals and are locked on to the tube; Advantage of causing minimal damage to
the tube, but their disadvantage is a higher failure rate.
 The Filshie clip, has a titanium frame lined by silicone rubber, has
the lowest failure rate (0.5%) and is easier to apply.
 Yoon or Fallope rings are applied over a loop of tube associated
with greater abdominal pain postoperatively, and the failure rates
vary between 0.3-4%.
o Tubal coagulation and division. Sterilization is effected by either
unipolar or bipolar diathermy of the tubes in two sites 1–2 cm from the uterotubal
junction.; reduce the risk of ectopic pregnancy. The failure rate depends on the
length of tube destroyed.
o Tubal ligation. performed through a mini-laparotomy or at the time of caesarean
section. The most basic form of the procedure involving simple ligation of the tube is
known as the Madlener procedure but the failure rate may be up to 3.7%. The
Pomeroy technique is the same, but the loop of tube is excised and absorbable suture
material is used for the ligation.
o The Essure® procedure. consists of insertion of a small device into each tube at the
time of a hysteroscopic examination, with this device resulting in fibrosis and
ultimate occlusion of the tube on each side.
Male Sterilization: Vasectomy
 This procedure is generally performed under local anaesthesia; 3-4 cm of the vas deferens is
excised; The advantage of the technique is its simplicity.
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 The disadvantages are that sterility is not immediate and should not be assumed until all
spermatozoa have disappeared from the ejaculate; On avg, this takes at least 10 ejaculations.
 The procedure is more difficult to reverse even when satisfactory re-anastomosis is achieved,
only abo ut 50% of patients will sire children; The failure rate is 1/2000.
o ose, they should be taken at the same time every day.
 y contraception prevents 85% of expected pregnancies. If the woman concerned.

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Topic 20: Termination of pregnancy (pp 303- 305)

This requires that two doctors agree that either continuation of the pregnancy would involve greater
risk to the physical or mental health of the mother or her other children than termination, or that the
fetus is at risk of an abnormality likely to result in it being seriously handicapped.
The most recent amendment to the Act set a limit for termination under the first of these categories at
24 weeks, although in practice the majority of terminations are carried out prior to 20 weeks.

Methods
 Prior to any intervention:
o Screening for STIs and/or offered antibiotic prophylaxis.
o Anti-D immunoglobulin should be given to all rhesus negative women.
o Follow-up appointment to check that there are no physical problems and that
contraceptive measures are in place.
 Surgical termination
o Most commonly used in the first trimester.
o The cervix is dilated by a number of millimetres equivalent to the gestation in weeks
and the conceptus is removed using a suction curette.
o Although most procedures are carried out under general anaesthesia, local
anaesthesia is widely used in for terminations before 10 weeks and reduces the time
the patient needs to stay in the hospital or clinic.
 Medical termination
o This is the method most commonly used for pregnancies after 14 weeks and is
increasingly being offered as an alternative to surgical termination in first trimester
pregnancies up to 9 weeks gestation.
o The standard regimens for first-trimester termination use the progesterone
antagonist mifepristone orally, followed 36-48 hours later by prostaglandins
administered as a vaginal pessary.
o Success rate of greater than 95%.
o Second trimester terminations can also be performed using vaginal prostaglandins
given 3-hourly or as an extra-amniotic infusion through a balloon catheter passed
through the cervix.
Complications
 Early complications include bleeding, uterine perforation (with possible damage to other
pelvic viscera), cervical laceration, retained products and sepsis.
 All the procedures also have a small failure rate (overall rate 0.7/1000).
 Late complications: infertility, cervical incompetence, isoimmunization and psychiatric
morbidity.

Psychological sequelae of termination

 The majority of women who find themselves with an unwanted pregnancy are very distressed.
 The majority of women do not experience medium- to long-term psychological sequelae, nor
is there any evidence of an increase in the rate of psychiatric morbidity.
 Risk factors for adverse sequelae of first-trimester abortion mostly Guilt and regret.
 Later terminations of pregnancy after 12 weeks:
o A minority of these women are having a therapeutic abortion for psychosocial
reasons;
o Majority terminates due to fetal abnormality.
o Associated both with marked psychological distress and an increased rate of
psychiatric disorder.
Contraception following termination
 The procedure can be combined with sterilization.
 IUD insertion can be carried out at the same time as termination and is not associated with an
increased risk of perforation or failure.
 If the oral contraceptive is being used, this can be started on the same or following day.

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Topic 21: Lower genital tract infections (pp 305- 309)

The commonest infections of the genital tract are those that affect the vulva and vagina. Infections that
affect the vagina also produce acute and chronic cervicitis.

Symptoms
 Swelling and reddening of the vulval skin is accompanied by soreness, pruritus and
dyspareunia.
 In case of vaginitis, vaginal discharge, pruritus, dyspareunia and often dysuria.
 Cervicitis is associated with purulent vaginal discharge, sacral backache, lower abdominal pain,
dyspareunia and dysuria.
 The proximity of the cervix to the bladder often results in coexistent trigonitis and urethritis,
particularly in the case of gonococcal infections.
Signs
 These will depend on the cause. The appearance of the vulval skin is reddened, sometimes
with ulceration and excoriation.
 In the sexually mature female, the vaginal walls may become ulcerated, with plaques of white
monilial discharge adherent to the skin or, in protozoal infections, the discharge may be
copious with a greenish-white, frothy appearance.
 Bartholin’s duct infection results in closure of the duct and formation of a Bartholin’s cyst or
abscess; Bartholinitis is readily recognized by the site and nature of the swelling.
 In cervicitis the cervix appears reddened and may be ulcerated, as with herpetic infections,
and there is a mucopurulent discharge as the endocervix is invariably involved.
o The diagnosis is established by examination and taking cervical swabs for culture.

Common organisms causing lower genital tract infections

 Vaginal candidiasis: Candida albicans is a yeast pathogen that occurs naturally on the skin and
in the bowel. Infection may be asymptomatic or associated with an increased or changed
vaginal discharge associated with soreness and itching in the vulva area.
o There is no evidence of male to female sexual transmission.
o White curd-like collections attached to the vaginal epithelium.
o Particularly common during pregnancy, in women taking the contraceptive pill and in
underlying conditions involving immunosuppression.
 Trichomoniasis: Trichomonas vaginalis is a flagellated single-celled protozoal organism that
may infect the cervix, urethra and vagina.
o In the male the organism is carried in the urethra or prostate and infection is sexually
transmitted.
o The commonest presentation is with abnormal vaginal bleeding, but other symptoms
include vaginal soreness and pruritus.
o A fresh wet preparation in saline of vaginal discharge will show motile trichomonads
 Genital herpes: The condition is caused by HSV type 2 and, less commonly, type 1. It is a
sexually transmitted disease.
o Primary HSV infection is usually a systemic infection with fever, myalgia and
occasionally meningism; The local symptoms include vaginal discharge, vulval pain,
dysuria and inguinal lymphadenopathy. The discomfort may be severe enough to
cause urinary retention.
o Vulval lesions include skin vesicles and multiple shallow skin ulcers.

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 Bacterial vaginosis: Gardnerella spp. It is not sexually transmitted. It may be asymptomatic or

cause a smelly vaginal discharge and vulval irritation.
o Associated with an increased risk of PID, UTI and puerperal infection.
o Diagnosis is made by finding three of the following:
 An increase in vaginal pH of more than 4.5.
 A typical thin homogenous vaginal discharge.
 A fishy odour produced when 10% KOH is added to the discharge.
 Clue cells on Gram-stained slide of vaginal fluid
 Gonococcal and chlamydial vulvovaginitis: These organisms can result in extensive pelvic
infection but may also be asymptomatic or indicated merely by vaginal discharge and dysuria;
Chlamydia is the commonest sexually transmitted infection seen today.
 Syphilis: spirochaete Treponema pallidum. The primary lesion or chancre most commonly
occurs on the vulva but may also occur in the vagina or cervix; may be accompanied by
inguinal lymphadenopathy, heals spontaneously within 2–6 weeks.
o Some 6 weeks after the disappearance of the chancre, the manifestations of
secondary syphilis appear. A rash develops which is maculopapular and is often
associated with alopecia.
 Genital warts (condylomata acuminata): Vulval and cervical warts are caused by a human
papilloma virus (HPV). The condition is commonly, although by no means invariably,
transmitted by sexual contact; The incubation period is up to 6 months.
o The warts have an appearance similar to those seen on the skin in other sites, and in
the moist environment of the vulval skin are often prolific- particularly during
pregnancy; There is frequently associated pruritus and vaginal discharge.

Treatment of lower genital tract infections

 Whenever a diagnosis of sexually transmitted infection is made, it is essential to screen
patients (and their partners) for other infections.
 Vulval and vaginal monilial infections can be treated by topical or oral preparations.
o i.e: single dose of clotrimazole given as a pessary or fluconazole taken orally.
o Recurrent infections can be treated by oral administration of ketoconazole and
fluconazole.
o The patient’s partner should be treated at the same time, and any predisposing
factors such as poor hygiene or diabetes should be corrected.
 Trichomonas infections and bacterial vaginosis are treated with metronidazole, which must be
taken by both sexual partners if recurrence of the infection is to be avoided.
o Topical treatment with metronidazole gel or clindamycin cream is also effective for
bacterial vaginosis.
o If a patient is asymptomatic and there is no evidence of vaginitis on clinical
examination, but trichomonal or monilial organisms are identified in a routine Pap
smear, treatment of these patients is usually not required.
 Non-specific vaginal infections are common and are treated with vaginal creams, including
hydrargaphen, povidone-iodine, quinoline or sulphonamide creams, in the case of coinfection,
hydrochloride or other antibiotics can be used.
 Infections of the vagina associated with menopausal atrophic changes are treated by the
appropriate hormone replacement therapy using an oral or vaginal oestrogen preparation.
o The same therapy may be used, with the local application of oestrogen creams, in
juvenile vulvovaginitis.
 Infections of Bartholin’s gland are treated with the antibiotic appropriate to the organism; In
case of abscess formation the abscess should be ‘marsupialized’ by excising an ellipse of skin
and sewing the skin edges to result in continued open drainage of the abscess cavity.
 Vulval warts are treated with either physical or chemical diathermy.
 Herpetic infections are notoriously resistant to treatment and highly prone to recurrence. The
best available treatment is aciclovir administered in tablet form 200mg/ 5 days.
 Acute cervicitis usually occurs in association with generalized infection of the genital tract and
is diagnosed and treated according to the microbiology.

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Topic 22: Upper genital tract infections (pp 309- 312)

 Acute infection of the endometrium, myometrium, Fallopian tubes and ovaries are usually the
result of ascending infections from the lower genital tract causing PID.
 Infection may be secondary to appendicitis or other bowel infections, which sometimes give
rise to a pelvic abscess.
 Perforation of the appendix with pelvic sepsis remains a common cause of tubal obstruction
and subfertility.
 Retained placental tissue and blood provide an excellent culture medium for organisms from
the bowel, including Escherichia coli, C. perfringens, S. aureus and Streptococcus faecalis.

Symptoms and signs

 The symptoms of acute salpingitis include:
o Acute bilateral lower abdominal pain: Salpingitis is almost invariably bilateral; where
the symptoms are unilateral, an alternative diagnosis should be considered
o Deep dyspareunia
o Abnormal menstrual bleeding
o Purulent vaginal discharge.
 The signs include:
o Signs of systemic illness with pyrexia and tachycardia.
o Signs of peritonitis with guarding, rebound tenderness and often localized rigidity
o On pelvic examination, acute pain on cervical excitation and thickening in the vaginal
fornices, which may be associated with the presence of cystic tubal swellings due to
pyosalpinges or pus-filled tubes; fullness in the pouch of Douglas suggests the
presence of a pelvic abscess.
o An acute perihepatitis may occurs in chlamydial PID, which may cause right upper
quadrant abdominal pain, deranged liver function tests and multiple filmy adhesions
between the liver surface and the parietal peritoneum, and is known as the Fitz–
Hugh–Curtis syndrome.
o A pyrexia of 38°C or more, sometimes associated with rigors.
Common organisms
 Chlamydia
o It is the commonest bacterial sexually transmitted infection and is thought to be the
causative agent in at least 60% of cases of PID.
o The main sites of infection are the columnar epithelium of the endocervix, urethra
and rectum, but many women remain asymptomatic.
o Ascent of infection to the upper genital tract may coexist with cervical infection.
 Gonorrhoea
o Infection is commonly asymptomatic or associated with vaginal discharge.
o In cases of PID it spreads across the surface of the cervix and endometrium and
causes tubal infection within 1-3 days of contact.
Differential diagnosis
The differential diagnosis includes the following:
 Tubal ectopic pregnancy
 Acute appendicitis.
 Acute urinary tract infections
 Torsion or rupture of an ovarian cyst.

Investigations
 History and general examination, swabs should be taken from the vaginal fornices and cervical
canal and sent to the laboratory for culture, ELISA (Chlamydia), PCR and antibiotic sensitivity.
 Examination of the blood for differential WBC, Hbestimation and CRP.
 The diagnosis of mild to moderate degrees of PID on the basis of history and examination
findings is unreliable and, where the diagnosis is in doubt, laparoscopy is indicated.

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Management
 When the patient is unwell and exhibits peritonitis, high grade fever, vomiting or a pelvic
inflammatory mass, she should be admitted to hospital and managed as follows:
o Fluid replacement by IV therapy – vomiting and pain often result in dehydration.
o When PID is clinically suspected, antibiotic therapy should be commenced.
 Antibiotic therapy initially prescribed antibiotic such as cefuroxime and
metronidazole given intravenously with oral doxycycline until the acute
phase of the infection begins to resolve.
o Pain relief with non-steroidal anti-inflammatory drugs.
o If the uterus contains an intrauterine device, it should be removed as soon as
antibiotic therapy has been commenced.
o Bed rest – immobilization is essential until the pain subsides.
o Abstain from intercourse.
 Patients who are systemically well can be treated as outpatients, with a single dose of
azithromycin and doxycycline, reviewed after 48 hours.
 Indications for surgical intervention
o In most cases, conservative management results in complete remission.
o Laparotomy is indicated where the condition does not resolve with conservative
management and where there is a pelvic mass.
 In most cases, the mass will be due to a pyosalpinx or tubo-ovarian abscess.
 This can either be drained or a salpingectomy can be performed.

Chronic pelvic infection

 Acute pelvic infections may progress to a chronic state with dilatation and obstruction of the
tubes forming bilateral hydrosalpinges with multiple pelvic adhesions.
 Symptoms are varied but include:
o chronic pelvic pain
o chronic purulent vaginal discharge
o epimenorrhagia and dysmenorrhea
o deep-seated dyspareunia
o infertility.
 Chronic salpingitis is also associated with infection in the connective tissue of the pelvis known
as parametritis.
 On examination, there can be a purulent discharge from the cervix; The uterus is often fixed in
retroversion, and there is thickening in the fornices and pain on bimanual examination.
 Conservative management of this condition is rarely effective and the problem is only
eventually resolved by clearance of the pelvic organs.
o Women with a history of PID are 8 times more likely to have a hysterectomy than the
general population.
o If the problem is mainly infertility due to tubal disease, the best treatment is IVF.
o Tubal removal prior to IVF is usually indicated if hydrosalpinges are present because
this improves the pregnancy rate achieved.

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Topic 23: Disorders of sexual dysfunction (pp 313- 315)

Dyspareunia
 Dyspareunia is defined as painful intercourse.
 The aetiology is divided on the basis of whether the problem is superficial (at the entrance to
the vagina) or deep (only occurs with deep penile insertion) and it is therefore particularly
important to obtain a concise history.
 Superficial dyspareunia: Pain felt on penetration is generally associated with a local lesion of
the vulva or vagina from one of the following causes:
o Infection: Local infections of the vulva and vagina or Bartholin’s glands.
o Narrowing of the introitus may be congenital, with a narrow hymenal ring, vaginal
stenosis, vaginal septum or over-vigorous suturing of an episiotomy wound or vulval
laceration or following vaginal repair of a prolapse.
o Menopausal changes: Atrophic vaginitis or the narrowing of the introitus and the
vagina from the effects of oestrogen deprivation.
o Vulvodynia: This is a condition of unknown etiology characterized by persisting pain
over the vulva.
o Functional changes: Lack of lubrication associated with inadequate sexual stimulation
and emotional problems will result in dyspareunia.
 Deep dyspareunia: Pain on deep penetration is often associated with pelvic pathology. Any
woman who develops deep dyspareunia after enjoying a normal sexual life should be
considered to have an organic cause for her pain until proved otherwise. The common causes
of deep dyspareunia include:
o Acute or chronic PID: including cervicitis, pyosalpinx and salpingooophoritis.
o Retroverted uterus and prolapsed ovaries: If the ovaries prolapse into the pouch of
Douglas and become fixed in that position, intercourse is painful on deep
penetration.
o Endometriosis: Both the active lesions and the chronic scarring.
o Neoplastic disease of the cervix and vagina.
o Postoperative scarring: This may result in narrowing of the vaginal vault and loss of
mobility of the uterus.
o Foreign bodies: Occasionally, a foreign body in the vagina or uterus may cause pain in
either the male or female partner
 Apareunia: ‘absence’ of intercourse or the inability to have intercourse at all. The common
causes are congenital absence of the vagina and imperforate hymen.
 Treatment (dependent of the cause)
o Congenital absence of the vagina can be successfully treated by surgical correction
(vaginoplasty) and removal of the imperforate hymen is effective.
o Medical treatment for deep dyspareunia includes the use of antibiotics and
antifungal agents; local oral hormone therapy for post-menopausal atrophic vaginitis.
o Surgical treatment includes correction of any stenosis, excision of painful scars.
o Reassurance and sexual counselling is necessary in functional disorders.
Vaginismus
 Vaginismus is the symptom resulting from spasm of the pelvic floor muscles and adductor
muscles of the thigh, which prevents or results in pain on attempted penile penetration.
 The woman may be unable to allow anyone to touch the vulva.
 Primary vaginismus is usually due to fear of penetration.
 Secondary vaginismus is more likely to be the result of an experience of pain with intercourse
after infection, sexual assault, a difficult delivery or surgery.
Loss of libido
 Loss of desire is the commonest symptom in women complaining of sexual dysfunction.
 If it has always been present it may be a result of a repression of sexual thoughts as a result of
upbringing or religious belief or a feeling that sex is dirty or unsuitable in some way.

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 It may represent differences between the expectations of the couple. Loss of desire in a
relationship that was previously satisfactory is more likely to be due to:
o major life events – marriage, pregnancy
o being ill, depressed or grieving
o endocrine or neurological disorders
o pain on intercourse
o medication (nacotics, sadatives, cytotoxic ect.)
o menopause
o fear of pregnancy or infection
o stress or chronic anxiety
 Helping the couple to look at the underlying reasons involved helps to identify what they
might do to correct the situation; Loss of libido is a feature of menopausal symptoms this will
occasionally respond to low dose testosterone therapy, along with conventional oestrogen
hormone replacement therapy.
Orgasmic dysfunction
 About 5-10% of women have not experienced orgasm by the age of 40 years.
 Orgasmic dysfunction is often linked to myths about it being the responsibility of the man to
bring the woman to orgasm.
 The problem can be helped breaking down inhibitions about self-stimulation and encouraging
better communication during foreplay and intercourse.

Disorders of Male Sexual Function

 Normal male sexual function is largely mediated through the autonomic nervous system.
 Erection occurs as a result of parasympathetic (cholinergic) outflow causing vasocongestion.
o Orgasm and ejaculation are predominantly sympathetic (adrenergic).
 Ejaculation is stimulated by the dorsal nerve of the penis and involves contractile activity of
the bulbocavernous and ischiorectal muscles as well as the posterior urethra.
 These responses are easily inhibited by cortical influences or by impaired hormonal, neural or
vascular mechanisms.
 The principal features of sexual dysfunction in men are:
Erectile dysfunction
 Erectile dysfunction or impotence, the inability in the male to achieve erection for satisfactory
penetration of the vagina, is the most common problem seen.
 It is now recognized that a high proportion (50%) of such men, especially those over the age
of 40 years, have an underlying organic cause. Of these diabetes is the commonest as a result
of damage to the large and small blood vessels and neuropathy.
 In the younger age group the cause is more likely to be psychogenic; Depression, reactive or
endogenous, is an important aetiological or concomitant condition. Mild psychogenic cases
will usually respond to simple measures such as counselling, sex therapy and sensate focusing
exercises.
 Intracavernous injection of prostaglandin E1 is effective in patients with both psychogenic and
organic causes of erectile dysfunction, although pain and the fear of injection cause some
patients to stop treatment.
 Sildenafil is an effective orally administered alternative. It promotes erection by potentiating
the effect of nitric oxide on vascular smooth muscle, thus increasing blood flow to the penis.
Ejaculatory problems
 Ejaculatory dysfunction encompasses premature, retarded, retrograde and absent ejaculation.
 Anejaculation and premature ejaculation are more often seen in younger patients.
 Retrograde ejaculation is often a result of an organic cause or after surgery, e.g. prostate
operations. The diagnosis is usually made on the presenting history.
 For premature ejaculation the squeeze technique described by pressure to top of the penis.
 Anejaculation and retarded ejaculation can be treated by teaching masturbation techniques,
couple counselling and sensate focus exercises.
 Retrograde ejaculation is regarded mainly as a fertility problem. Treatment may involve
surgery or drug therapy with alpha-adrenoceptor agonists.

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Topic 24: Neoplastic lesions of the vulva and the vagina (pp 317- 321)

Vulval intraepithelial neoplasia (VIN)

 Condition characterized by disorientation and loss of epithelial architecture extending through
the full thickness of the epithelium.
 VIN is categorized into usual VIN (classic VIN or Bowen’s disease) and differentiated VIN (d-
VIN) based on the distinctive pathological features.
o Squamous VIN
 Usual VIN (formerly classic VIN or Bowen’s disease)
 Differentiated VIN (formerly ‘simplex’ VIN)
o Non-squamous VIN: Paget’s disease
 Usual VIN often occurs in young women between 30–50 years and is associated with cigarette
smoking and HPV infection; can be asymptomatic, or they may complain of pruritus, pain,
dysuria and ulceration.
 Lesions can be white, pink or pigmented, in the forms of plaques or papules, most frequently
found in labia and posterior fourchette.
 d-VIN is rare and occurs in post-menopausal women. It is associated with squamous
hyperplasia, lichen sclerosus and lichen simplex chronicus, and is considered as the precursor
of most HPV negative invasive keratinizing squamous cell carcinomas.
o Similar symptoms as for lichen sclerosus: Grey, white, red nodules, plaques or ulcers.
 Paget’s disease is associated with underlying adenocarcinoma or primary malignancy
elsewhere, mainly breast and bowel.
 It is important to establish the diagnosis by biopsy and to search for intraepithelial neoplasia
in other sites like the cervix and vagina, particularly when usual VIN is found.
 Treatment of usual VIN includes imiquimod, an immune modifier, laser therapy, and
superficial excision of the skin lesion.
 Recurrence is common and because there is a risk of malignant progression especially in d-
VIN, long-term follow-up is essential.

Cancers of the vulva

 Carcinoma of the vulva accounts for 1–4% of female malignancies: 90% of the lesions are
squamous cell carcinomas, 5% are adenocarcinomas, 1% are basal carcinomas.
 Carcinoma of the vulva most commonly occurs in the sixth and seventh decades.
 Vulvar cancer has two distinct histological patterns with two different risk factors.
o The more common basoloid/ warty types occur mainly in younger women and are
associated with usual VIN and HPV infection.
o The keratinizing types occur in older women and are associated with lichen sclerosus.
 Patient experiences pruritus and notices a raised lesion on the vulva, which may ulcerate and
bleed; most frequently develops on the labia majora but may also grow on the prepuce of the
clitoris, the labia minora, Bartholin’s glands and in the vestibule of the vagina.
 Spread occurs both locally and through the lymphatic system. The lymph nodes involved are
the superficial and deep inguinal nodes and the femoral nodes.
 The disease usually progresses slowly and the terminal stages are accompanied by extensive
ulceration, infection, haemorrhage and remote metastatic disease
 Treatment
o Stage IA disease can be treated by wide local excision.
o Stage IB lesions that are at least 2 cm lateral to the midline are treated by wide local
excision and unilateral groin node dissection.
o All other stages are treated by wide radical local excisions or radical vulvectomy and
bilateral groin node dissection.
o Postoperative radiotherapy may be used in cases of extensive disease to reduce the
tumour volume.
o Response to chemotherapy (bleomycin) is generally poor.
o Patients are followed up at intervals of 3–6 months for 5 years.
 Good Prognosis

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Vaginal intraepithelial neoplasia (VAIN)

 Usually multicentric and tends to be multifocal, associated with similar lesions of the cervix.
 Asymptomatic and tends to be discovered because of a positive smear test or during
colposcopy for abnormal cytology, often after hysterectomy.
 There is a risk of progression to invasive carcinoma, but the disease remains superficial until
then and can be treated by surgical excision, laser ablation or cryosurgery.

Vaginal adenosis
 This is the presence of columnar epithelium in the vaginal epithelium and has been found in
adult females whose mothers received treatment with diethylstilboestrol during pregnancy.
 The condition commonly reverts to normal squamous epithelium, but in about 4% of cases
the lesion progresses to vaginal adenocarcinoma follow carefully with serial cytology.

Vaginal malignancy
 Invasive carcinoma of the vagina may be a squamous carcinoma or, occasionally, an
adenocarcinoma.
 Primary lesions arise in the sixth and seventh decades.
 The incidence of adenocarcinoma, typically clear cell, associated with in utero exposure of
diethylstilbestrol has declined since this drug was withdrawn from use in pregnancy.
 Secondary deposits from cervical carcinoma and endometrial carcinoma are relatively
common in the upper third of the vagina and can sometimes occur in the lower vagina
through lymphatic spread.
 The symptoms include irregular vaginal bleeding and offensive vaginal discharge when the
tumour becomes necrotic and infection supervenes.
 Local spread into the rectum, bladder or urethra may result in fistula formation.
 The tumour may appear as an exophytic lesion or as an ulcerated, indurated mass.
 Tumour spread occurs by direct infiltration or by lymphatic extension.
 Lesions involving the upper half of the vagina follow a pattern of spread similar to that of
carcinoma of the cervix. Tumours of the lower half of the vagina follow a similar pattern of
spread to that of carcinoma of the vulva.
 The diagnosis is established by biopsy; Staging is made before commencing treatment.
 The primary method of treatment is by radiotherapy – both by external beam therapy and
brachytherapy.
 Surgical treatment can also be considered in selected patients.
o radical hysterectomy or vaginectomy and pelvic lymph node dissection can be
considered in patients with stage I disease in the upper vagina.
o radical vulvectomy may be needed in stage I disease in the lower vagina
o pelvic exenteration may be considered in patients with localized metastatic disease
to the bladder or rectum without parametrial or lymph node metastasis.
 Good prognosis.

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Topic 25: Lesions of the cervix (pp 321- 327)

Screening for cervical cancer

 The aim of cervical screening programmes is to detect the non-invasive precursor of cervical
cancer, cervical intraepithelial neoplasia (CIN), in the asymptomatic population in order to
reduce mortality and morbidity.
 In taking a cervical cytology cells are taken from around the cervix from the whole of the
transformation zone with a 360° sweep.
o Cervical cytology is primarily for screening for squamous lesions and cannot reliably
exclude endocervical disease.

Classification of cervical cytology

 The term dyskaryosis is used to describe those cells that lie between normal squamous and
frankly malignant cells and exhibit degrees of nuclear changes before malignancy
Cells showing abnormalities that fall short of dyskaryosis are described as borderline.
 Malignant cells show nuclear enlargement at the expense of cytoplasmic mass. The nuclei
may assume a lobulated outline with an increased intensity of staining of the nucleus and an
increase in the number of mitotic figures.
 Colposcopy is inspection of the cervix using a binocular microscope with a light source. It is
usually an outpatient procedure performed using a speculum to expose the cervix.
o Squamous neoplasia most often occurs in
the areas adjacent to the junction of the
columnar (velvety red) and squamous
(smooth pink) epithelium or the squamo–
columnar junction (SCJ). If this cannot be
seen in its entirety, CIN cannot be
excluded by colposcopic examination and
a cone biopsy will be required.

 Colposcopic appearances:
o Neoplastic cells have an increased amount of nuclear material in relation to
cytoplasm and less surface glycogen than normal squamous epithelium.
o They are associated with a degree of hypertrophy of the underlying vasculature.
o When exposed to 5% acetic acid the nuclear protein will be coagulated, giving the
neoplastic cells a characteristic white appearance.
o Small blood vessels beneath the epithelium may be seen as dots (punctation) or a
crazy paving pattern (mosaicism) due to the increased capillary vasculature.
o The diagnosis is confirmed by biopsies taken from the most abnormal-looking areas.
o Early invasive cancer is characterized by a raised or ulcerated area with abnormal
vessels, friable tissue and coarse punctation with marked mosaicism.

Human papilloma virus

 Certain types of HPV are found in association with neoplastic changes in the cervix.
o Types 6 and 11 are associated with low-grade CIN and condylomata, whereas 16 and
18 are associated with high grades of CIN and carcinoma of the cervix.
o HPV is considered as the necessary though not sole cause of cervical cancer- It is
present in 95% of squamous cell cervical cancers and 60% of adenocarcinomas.
o Cervical cancer could be reduced by immunization against HPV as the prevention of
infection of specific high-risk HPV types could prevent development of cervical
cancer from those particular types.

Cervical intraepithelial neoplasia

 This is a histological diagnosis, usually made from colposcopic-directed biopsy, of changes in
the squamous epithelium characterized by varying degrees of loss of differentiation and
stratification and nuclear atypia.
 It may extend up to 5 mm below the surface of the cervix by involvement of crypt epithelium
in the transformation zone, but does not extend beyond the basement membrane.

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 The aetiology is the same as that of invasive disease but with a peak incidence 10 years
earlier.
 CIN is graded as mild (CIN-1), moderate (CIN-2) or severe (CIN-3) depending on the proportion
of the epithelium replaced by abnormal cells.
o 25% per cent of CIN 1 will progress to higher grade lesions over 2 years,
o 30–40% of CIN-3 to carcinoma over 20 years
o 40% of low-grade lesions (CIN-1) will regress to normal within 6 months without
treatment especially in the younger age group.
 Cervical glandular intraepithelial neoplasia is the equivalent change occurring in the columnar
epithelium and is associated with the development of adenocarcinoma of the cervix.
 Treatment:
o Low-grade CIN can be managed by cytological and colposcopic surveillance at 6
monthly intervals as progress to invasive disease does not occur within 6 months, or
it can be treated as for higher grade lesions.
o Higher grade lesions (CIN-2 and 3 and dyskaryotic glandular cells) are an indication
for immediate treatment either by excision or destruction of the affected area
(usually the whole of the transformation zone) by LASER ablation, cryocautery and
coagulation diathermy; Excision can be carried out using scalpel, LASER or using a
diathermy loop wire (large loop excision of the transformation zone,
 Complications of cone biopsy is haemorrhage; Primary, i.e. within 12 hours of operation, or
secondary, usually between 5 days and 12 days after the operation.
Later complications include cervical stenosis with dysmenorrhea and haematometra.

Cervical cancer
 Cervical cancer is the second commonest female cancer worldwide.
 Cervical cancer has a direct relationship to sexual activity; Associated risk factors are early age
of first intercourse, number of partners, smoking, low socioeconomic status, infection with
HPV and immunosuppression.
 Affects young women, with a peak incidence at 35–39 years.
 There are two types of invasive carcinoma of the cervix:
o 70–80% of lesions are squamous cell carcinoma
o 20–30% adenocarcinomas.
o Histologically, the degree of invasion determines the stage of the disease
 Cervical carcinoma spreads by direct local invasion and via the lymphatics and blood vessels.
 Clinical signs:
o Stage IA disease is usually asymptomatic at the time of presentation and is detected
at the time of routine cervical cytology.
o The common presenting symptoms from invasive carcinoma of the cervix include
postcoital bleeding, foul-smelling discharge, which is thin and watery and sometimes
blood-stained, and irregular vaginal bleeding when the tumour becomes necrotic.

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 Lateral invasion into the parametrium may involve the ureters, leading eventually to ureteric
obstruction and renal failure.
o Invasion of nerves and bone causes excruciating and persistent pain, and
involvement of lymphatic channels may result in lymphatic occlusion with intractable
oedema of the lower limbs.
o The tumour may also spread to involve the bladder or rectum and produces
symptoms of frequency, dysuria and haematuria; if the bowel is involved, tenesmus,
diarrhea and rectal bleeding may occur.
o The neoplasm may initially grow within the endocervix, producing a cylindrical,
barrel-shaped enlargement of the cervix with little external manifestation of the
tumour; The exophytic tumour grows over the vaginal portion of the cervix and
appears as a cauliflower-like tumour.
 The tumour eventually sloughs and replaces the normal cervical tissue and
extends on to the vaginal walls.
 Diagnosis:
o The diagnosis is established histologically by biopsy of the tumour, which should be
greater than 5 mm in depth to distinguish between microinvasive and invasive
disease.
o MRI of the abdomen and pelvis is performed for assessment of the parametrium and
lymph node status; CT thorax may also be needed if lung metastasis is suspected.
 Treatment of invasive carcinoma
o surgery or radiotherapy/chemoradiation or a combination of both methods.
o Local excision carried out by cone biopsy is an option for patients with stage IA
lesions who wish to preserve fertility.
 Simple hysterectomy suffices for stage IA1 for those who have completed
family.
 Extended hysterectomy or radiotherapy can be used to treat stage IB–IIA.
 The cure rate is similar for both surgery and radiotherapy, but the former is
generally associated with less long-term morbidity from vaginal stenosis.
 Surgery can also preserve ovarian function for those pre-menopausal
women.
o Stage II–IV disease is usually treated with chemoradiation with weekly platinum
based chemotherapy and intracavity and external beam radiotherapy.
o Surgery – radical hysterectomy and pelvic lymph node dissection
 Radical hysterectomy includes removal of the uterus, parametrium, and the
upper third of the vagina. The ovaries may be conserved. This method of
treatment, together with internal and external iliac and obturator lymph
node dissection, is appropriate for patients with stage IB1 and early stage
IIA1 diseases.
o Complications include haemorrhage, infection, pelvic haematomas,
lymphocyst/lymphoedema, bladder dysfunction and damage to the ureters or
bladder, which may result in fistula formation.
o Radiotherapy/Chemoradiation to treat other stages of cervical cancer and those
patients with bulky stage IB disease or who are unfit for surgery.
o Adjuvant chemoradiotherapy is also used for those patients who have been found to
have lymph node involvement at the time of surgery.
o Chemotherapy is platinum based and given weekly in conjunction with radiotherapy.
 Prognosis depends mainly on the stage at diagnosis and lymph node status.
The results for 5 year survival are:
o stage I: 85%
o stage II: 60%
o stage III: 30%
o stage IV: 10%.
o The comparable survival figure for stage IB using radical surgery is 90%
 Recurrent cervical lesions occur in a third of cases and have a poor prognosis.

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Topic 26: Malignant disease of the uterus (pp 328- 331)

Endometrial carcinoma
 One of the commonest female cancers; mainly affects postmenopausal women with a peaks
incidence of women aged 60–75 years.
 There are specific factors associated with an increased risk of corpus carcinoma, such as
nulliparity, late menopause, diabetes and hypertension. It can also be hereditary.
 Women with hereditary non-polyposis colorectal cancer (HNPCC) syndrome have increased
risk of endometrial and ovarian cancers, as well as colorectal cancer.
 The most important risk factors are associated with hyperoestrogen state:
o Obesity: The ovarian stroma continues to produce androgens after the menopause,
which are converted to oestrone in adipose tissue. This acts as unopposed oestrogen
on the endometrium, resulting in endometrial hyperplasia and malignancy.
o Exogenous oestrogens: Unopposed oestrogen action, particularly as used for
hormone replacement therapy in the menopause, is associated with an increased
incidence of endometrial carcinoma. Addition of a progestogen reduces the risk.
o Endogenous oestrogens: Oestrogen-producing ovarian tumours, such as granulose
cell tumours are associated with an increase in the risk of endometrial cancer.
o Tamoxifen in breast cancer: slightly increased risk of endometrial cancer, but most of
these are detected in early stages and have good prognosis.
o Endometrial hyperplasia: Prolonged stimulation of the endometrium with unopposed
oestrogen may lead to hyperplasia of the endometrium with periods of amenorrhoea
followed by heavy or irregular bleeding.
 Symptoms
o The commonest symptom is postmenopausal bleeding.
o In premenopausal woman irregular vaginal bleeding and increasingly heavy menses.
o In elderly patients pyometra and usually present with purulent vaginal discharge.
 Endometrial carcinoma can be divided into two types:
o Type I (most endometroid cancers) refers to endometrioid adenocarcinoma. This
type is related to the hyperoestrogenic state and hence all the risk factors associated
with hyperoestrogenism, such as obesity, diabetes, unopposed oestrogen, etc.
o Type II represents other histological types, such as serous papillary and clear cell
subtypes. These tend to be aggressive tumours with poorer prognosis.
o The microscopic appearances include changes in the architecture with the
development of closely packed polyhedral cells with dark-staining nuclei and
considerable numbers of mitoses.
 Endometrial cancer grows locally and spreads by direct invasion into the myometrium and
then transcervically, transtubally and by spillage of carcinomatous material.
There can also be lymphatic spread to the pelvic and para-aortic nodes
 Initial investigations include a transvaginal ultrasound scan to assess the endometrial
thickness and an endometrial aspirate to obtain endometrial tissue for histological
assessment. CA- 125 may be raised.
o An endometrial thickness of less than 5 mm on transvaginal ultrasound in a
postmenopausal woman indicates a very low risk of endometrial cancer
o In women over 40 years old who have abnormal vaginal bleeding, an endometrial
aspirate should be the first line investigation to assess the endometrium done with
Pipelle sampler, a transparent plastic cannula with a very small diameter, e.g. 3 mm
that can be passed through the cervical os without dilation and can be done in the
office without anaesthesia.
o During a diagnostic hysteroscopy, a hysteroscope, which is a narrow rigid telescope,
is passed through the cervical os and the uterine cavity is distended by either gas or
fluid. This allows direct visualization of the uterine cavity and directed biopsies of any
endometrial lesions can be taken.
 The diagnosis of endometrial cancer is established histologically by endometrial biopsy result.
 The mainstay of treatment is total hysterectomy and bilateral salpingo-oophorectomy. useful
o Adjuvant radiotherapy is often given to patients with high risk of recurrence.
o Vaginal brachytherapy can reduce local vault recurrence.

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o Patients with advanced disease are treated by debulking the tumour followed by
chemotherapy with or without radiotherapy.
o Cytotoxic drugs such as carboplatin and doxorubicin are used in the treatment of
recurrent disease but response rates are low (20%).
 Prognosis
o Endometrial cancer is surgically staged. Prognosis largely depends on the stage of the
disease as well as other prognostic factors that include age, histological subtype and
grading.
o For stage I grade A, the 5-year survival can be over 90% for those with superficial
myometrial invasion
o Deep myometrial invasion and grade III disease, the 5-year survival is only about 60%
even if the disease is still confined to the uterus.
o For stage II, III and IV diseases, the 5-year survival is about 70–80%, 40–50% and
20%, respectively.

Malignant mesenchymal tumours of the uterus

Non-epithelial cancers account for only 3% of uterine malignancies.
Stromal sarcomas
o These tumours, arising from the stroma of the endometrium.
o They tend to present in a younger age group (45–50 years) than other uterine
tumours with vaginal discharge and bleeding.
o Associated with adenomyosis and endometriosis.
o It can be classified as low or high grade, depending on the number of mitotic figures
and similarity to the non-glandular elements of the endometrium.
o Malignant mixed mesodermal sarcomas contain elements of both smooth muscle
and stroma.
 Mixed mullerian tumours (carcinosarcomas)
o These tumours consist of both epithelial and mesenchymal elements.
 The epithelial elements are usually endometrioid but can be squamous or a
mixture.
 The stromal elements are either heterologous (chondroblastoma,
osteosarcoma, fibrosarcoma) or homologous (leiomyosarcoma,
presarcoma).
o The mean age at presentation is 65 years.
o An enlarged, irregular uterus with tumour protruding through the cervical os is a
common finding at examination.
o Extrauterine spread occurs early and only 25% of patients have disease limited to the
endometrium at the time of diagnosis.
 Leiomyosarcoma
o These smooth muscle tumours arise in the myometrium of the uterus.
o They are uncommon, with a peak incidence at the age of 52 years, about 10 years
later than the peak incidence for fibroids.
o Leiomyosarcomas are classified according to the degree of differentiation.
o They may present with pain, postmenopausal bleeding or a rapidly growing ‘fibroid’,
but are often asymptomatic and diagnosed following hysterectomy for fibroids.
o Treatment is by hysterectomy and bilateral salpingo-oophorectomy.
o Adjuvant radiotherapy and chemotherapy reduces the risk of local recurrence but
does not improve long-term survival.
Treatment
 This is by hysterectomy, with removal of as much macroscopic disease as possible, followed
by radiotherapy.
 Prognosis for low-grade stromal sarcomas is similar to that for endometrioid tumours, but
poor for others, with a 20-40% 5-year survival.

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Topic 27: Benign ovarian tumours (pp 331- 335)

Functional cysts of the ovary

These cysts occur only during menstrual life and rarely exceed more than 6 cm in diameter.
 Follicular cysts
o The commonest functional cysts in the ovary and may be multiple and bilateral.
o The cysts rarely exceed 4 cm in diameter, the walls consisting of layers of granulosa
cells and the contents of clear fluid, which is rich in sex steroids.
o Occur during treatment with clomiphene or human menopausal gonadotrophin.
o May produce prolonged unopposed oestrogen effects on the endometrium, resulting
in cystic glandular hyperplasia of the endometrium.
o They regress spontaneously but if they have not involuted after 60 days the diagnosis
should be revised. The size and growth of the cysts can be monitored by US scans.
o The prolonged and heavy menstrual loss caused by unopposed oestrogen action can
be offset by the administration of a progestogen for 1 week followed by ‘medical
curettage’/ through surgical intervention by cervical dilatation and uterine curettage.
 Lutein cysts There are two types of luteinized ovarian cyst:
o Granulosa lutein cysts, functional cysts of the corpus luteum, may be 4–6 cm in
diameter and occur in the second half of the menstrual cycle.
 Persistent production of progesterone may result in amenorrhoea or
delayed onset of menstruation.
 Give rise to pain and therefore present a problem in terms of differential
diagnosis, as the history and examination findings mimic tubal ectopic
pregnancy.
 Haemorrhage may occurs into the cyst rupture  haemoperitoneum.
 The cysts usually regress spontaneously and require surgical intervention
only when they give rise to symptoms of intra-abdominal haemorrhage.
o Theca lutein cysts commonly arise in association with high levels of chorionic
gonadotrophin and are therefore seen in cases of hydatidiform mole.
 The cysts may be bilateral and can give rise to haemorrhage if they rupture.
 Once the cysts have been formed, they can be detected by ultrasound.
 Usually undergo spontaneous involution but surgical intervention may be
necessary if there is significant haemorrhage from the ovaries.
Benign neoplastic cysts
These tumours may be cystic or solid and arise from specific cell lines in the ovary.
Epithelial tumours
 Serous cystadenomas. These cysts, in conjunction with mucinous cystadenomas, form the
commonest group of cystic ovarian tumours.
o May be unilocular- lined by a layer of cuboidal epithelium; multilocular with papillary
growths extending from internal & external surfaces of the tumor.
o The wall of the tumour sometimes contains calcified granules- psammoma bodies.
o May be bilateral and may be large enough to fill the peritoneal cavity.
o Often replace all normal ovarian tissue; if this is the case, the whole ovary should be
removed: If the tumour is small, it may be possible to perform a local resection and
to conserve ovarian tissue. If both ovaries are extensively involved or there is reason
to believe that the tumours are malignant, it is better to perform bilateral
oophorectomy and hysterectomy.
 Mucinous cystadenomas. These tumours are multilocular and often reach enormous
dimensions, with tumours weighing in excess of 100 kg recorded in the literature.
o The fluid content consists of mucin, and the epithelium lining the cysts presents a
characteristic appearance of a secretory epithelium of tall columnar cells with a
pseudostratified appearance.
o The demarcation between epithelial cells and stroma is sharply defined. There is little
tendency to form papillae. These tumours are less likely to become malignant than
the serous variety.
o The only treatment is to remove the tumour surgically.

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 Brenner cell tumours are commonly solid and occur in women after the age of 50 years. They
are only rarely malignant.
o The histological features of these tumours include nests of epithelial cells surrounded
by fibromatous connective tissue groundwork.
o The cut surface of the tumour is similar to that of an ovarian fibroma apart from a
rather yellowish tinge.
o The tumours are occasionally bilateral and can be safely treated by local excision.

Sex cord stromal tumours

Hormone-secreting tumours of the ovary are a small but important group.
 Granulosa cell tumours. Arising from ovarian granulosa cells, they produce oestrogens.
o As granulosa cell tumours can present at any age, the symptoms depend on the age
of occurrence.
o Tumours arising before puberty produce precocious sexual development, and in
women of the reproductive age, prolonged oestrogen stimulation results in cystic
glandular hyperplasia and irregular and prolonged vaginal bleeding.
o If the tumour is histologically benign, the surgery should be limited to oophorectomy.
o If there is evidence of malignancy, pelvic clearance is indicated.
 Thecomas or theca cell tumours arise from the spindle shaped thecal cells, but are often
mixed with granulosa cells and are oestrogen secreting.
o The presence of a thecoma in one ovary is commonly associated with diffuse
thecomatosis in the contralateral ovary.
 Arrhenoblastomas or androblastomas. These are tumours of Sertoli–Leydig cells.
o They are rare androgen-secreting tumours that occur most frequently in the decade
between 20- 30 years of age.
o Clinical manifestations include amenorrhoea, loss of breast tissue, increasing facial
and body hirsutism, deepening of the voice and enlargement of the clitoris.
o The diagnosis is established by the exclusion of virilizing adrenal tumours and the
identification of a tumour in one ovary.
o The condition is treated by excision of the affected ovary; ~25% are malignant.
Germ cell tumours
Tumours of germ cell origin may replicate stages resembling the early embryo.
 Mature cystic teratoma (dermoid cyst).
o Contain a large number of embryonic elements such as skin, hair, adipose and
muscle tissue, bone, teeth and cartilage- Some can be recognized on radiography.
o These tumours are often chance findings as they are commonly asymptomatic unless
they undergo torsion or rupture, when the release of sebaceous material causes an
acute chemical peritonitis.
o Dermoid cysts tend to be anterior to the uterus.
o They are bilateral in 12% of cases, usually benign but may become malignant(~2%).
o The growth of thyroid tissue (struma ovarii) may induce a state of hyperthyroidism.
o These cysts should be excised from the ovary with conservation of ovarian tissue.
Fibromas
These solid tumours of the ovary are rare. They may be associated with the presence of ascites or
hydrothorax – a condition known as Meigs’ syndrome.

Tumour-like conditions
 This group includes endometriotic cysts, pregnancy luteomas and germinal cell cysts.
 Treatment depends on the nature of the tumour, normally by simple excision of the cysts.
 Endometriotic cysts. Endometriomas contain chocolate-coloured fluid representing the
accumulation of altered blood, and have a thick fibrous capsule; The lining may consist of
endometrial cells but in old cysts these may disappear.

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Topic 28: Ovarian malignancy (pp 335- 338)

 It is the second most common gynaecological cancer after endometrial cancer, it is the
commonest cause of gynaecological cancer deaths.
 The incidence increases with age, with 80% being diagnosed in women over the age of 50
years. The poor survival is partly attributable to late diagnosis as many women present late
due to lack of obvious symptoms.
 The cause of ovarian cancer remains unknown but there are well defined risk factors.
o Genetics: About 1% of cases of ovarian cancer occur in women whose families show
an AD pattern of inheritance of breast and ovarian cancer. Many of these women
have been shown to have defects in the BRCA1or BRCA2 genes
o Parity and fertility: Multiparous women are at less risk than nulliparous, whereas
women who have had unsuccessful treatment for infertility seem to be at increased
risk. The use of the contraceptive pill may produce up to a 60% reduction in the
incidence of the disease
 Primary ovarian carcinoma
The distribution of histological types of ovarian cancers is as follows:
o Epithelial type. This makes up 85% of cases of ovarian malignancy. Epithelial tumours
include the following subtypes:
 Serous cystadenocarcinoma is the most common histological type of ovarian
carcinoma and is usually unilocular.
 Mucinous cystadenocarcinomas.
 Endometrioid cystadenocarcinomas
 Clear-cell cystadenocarcinoma is the most common ovarian malignancy
found in association with ovarian endometriosis.
 Brenner or transitional cell cystadenocarcinoma
 Tumours of low malignant or borderline potential
o Sex cord stromal tumours. These tumours are relatively rare. (~6% of ovarian cancer)
 Granulosa cell tumours: These solid, unilateral, haemorrhagic tumours are
the most common oestrogen-secreting lesions.
 Sertoli–Leydig cell tumours.
o Germ cell tumours
 Dysgerminomas
 Teratomas
 Endodermal sinus or yolk sac tumours. The most common germ cell tumour
in children.
 Secondary ovarian carcinomas
The ovaries are a common site for secondary deposits from primary malignancies in the
breast, genital tract, gastrointestinal system and haematopoietic system.
o Krukenberg’s tumours are metastatic deposits from the gastrointestinal system.
 They are solid growths that are almost always bilateral.
 The epithelial elements occur as clusters of well-marked acini with cells
exhibiting mucoid change, known as signet ring cells.
Staging of ovarian carcinoma
 Spread of primary ovarian tumours can be by direct extension, lymphatics or via the
bloodstream.
 Ideally, it should be staged at the time of laparotomy with inspection and biopsy of the
peritoneum and diaphragm, cytological examination of peritoneal fluid and pelvic and para
aortic lymph nodes dissection.

Diagnosis
 Early ovarian carcinomas are mostly asymptomatic.
 The commonest symptoms are abdominal discomfort or distension.
 Clinically, a pelvic mass may be detected and there may be ascites.
 CT or MRI scans may give an indication of spread.
 CA-125 is the widely used tumour marker for epithelial ovarian cancer.

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Management
 Treatment is based on surgery and chemotherapy.
o Surgery
 involves abdominal hysterectomy, bilateral salpingooophorectomy,
omentectomy and careful inspection and sampling of peritoneal surfaces
and retroperitoneal (pelvic and para-aortic) lymph node dissection.
 The aim is to remove all macroscopic disease.
 Surgery is often followed by adjuvant chemotherapy.
 Fertility sparing surgery, e.g. unilateral salpingo-oophorectomy with
preservation of the uterus and the other ovary should be considered even in
the presence of metastatic disease because the tumour is highly
chemosensitive.
o Chemotherapy
 Patients with high risk for recurrence, e.g. those with high grade, poor
histological subtypes or stage IC or above, are often given adjuvant
chemotherapy.
 The platinum-based drugs cisplatin and carboplatin are currently the
mainstay of treatment.
 Side effects: marrow suppression, neurotoxicity and renal toxicity.
 The overall response rate is up to 80%
 Borderline tumours: treated by unilateral oophorectomy in young women wishing to preserve
their reproductive capacity, although careful, long-term follow-up is required.
 Germ cell tumours: chemotherapy may be curative without hysterectomy.

Follow-up and treatment of recurrence

 Patients are followed up for any symptoms such as abdominal discomfort, tumour markers
and clinical examination.
 Chemotherapy is the main-stay of treatment for recurrence.
 Debulking of the tumour may be feasible if it is localized and there is a long time interval to
recurrence.
 In platinum-sensitive patient, re-challenge with first-line chemotherapy (carboplatin and
paclitaxel) is recommended.

Screening for ovarian cancer

 Because the prognosis for early stage disease is better than that for advanced disease, overall
survival might be improved if the disease could be diagnosed earlier in asymptomatic women.
 The two main methods proposed are ultrasound and CA-125 measurement.
o Combining transvaginal ultrasound with serial CA-125 can be a possible screening
strategy.

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Topic 29: Principles of palliative care in gynecological cancer (pp 338- 340)

 Despite optimal initial treatment, disease recurrence and progression are inevitable in a certain
proportion of women with gynaecological cancer.
 In many of these situations, a cure is no longer a realistic option but this by no means translates into
withdrawal of the input from medical professionals.
 A multi-disciplinary approach, with strong input from the palliative team to provide supportive care to
the individual is crucial.
 Palliative care aims to provide both physical and emotional support as well as preparation for the
eventual outcome of death.
 Quality of life and patient’s autonomy and dignity are the most important aspects in this final phase of
life.
 Good communication and a trusting relationship between the patient and her carers are key to
achieving these aims.
 The decision to either continue or stop anticancer treatment needs to take into account for the overall
benefit in quality of life, bearing in mind the additional stress and side effects arising from the
treatment rather than the disease.
 Uncontrolled symptoms can cause severe distress Symptom control is one of the main areas for
palliative care.
o Therapeutic measures can then be targeted at the mechanisms involved:
 NSAIDs drugs would be appropriate for pain arising from inflammation or antispasmodic agents for
bowel spasms
 Neuropathic pain can be relieved by tricyclic antidepressant or anticonvulsant drugs such as
gabapentin.
o Increasing the pain threshold involves good psychological support, possibly with the help of
antidepressant and anxiolytics.
 World Health Organization has developed a three-step ‘ladder’ for cancer pain relief and
administration of drugs should be in the following order:
o non-opioids (such as paracetamol and aspirin)
o mild opioids (codeine)
o strong opioids such as morphines.
 At each step, ‘adjuvant’ agents can be added.
 Adjuvants are medications that have a primary indication other than pain control but can also help to
relieve pain in certain situations, such as anticonvulsant and antidepressant agents.
 Opioids are very effective, but they need to be given at the right dose and at the right time on regular
intervals and additional doses can be prescribed as required for breakthrough pain.
- Common opioid side effects include nausea, vomiting and constipation, and therefore antiemetics and
regular laxatives should also be prescribed when starting opioids.
Patients should be reassured that appropriate use of opioids would not cause addiction.
 In women with extensive intra-abdominal disease, such as those in advanced ovarian cancer, bowel
obstruction and ascites are common.
o Symptoms from bowel obstructions are difficult to deal with entirely.
o Surgical intervention can potentially give the best palliative effect but is often not feasible due to
multiple sites of obstructions from extensive disease.
 Conservative management aims to reduce nausea and vomiting with anti- emetic ± nasogastic tube and
maintaining hydration by IV fluid.
 Occasionally, a trial of short-course corticosteroid drugs to decrease inflammatory oedema around the
bowels.
 Ascites from peritoneal disease can be effectively relieved by paracentesis or diuretics such as
spironolactone.
 Eventually, when the patient is very close to death, care plans should concentrate on providing a
peaceful and dignified environment for the patient and her family.

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Topic 30: Uterovaginal prolapse (pp 341- 348)

Vaginal prolapse
 Prolapse of the anterior vaginal wall may affect the urethra (urethrocele), and the bladder
(cystocele).
 On examination, the urethra and bladder can be seen to descend and bulge into the anterior
vaginal wall and, in severe cases, will be visible at or beyond the introitus of the vagina.
 Urethrocele is the result of damage to level III- anterior support (pubourethral ligaments).
 Cystoceles usually result due to a loss of level II support and usually due to a midline defect in
pubovesicocervical fascia.
 Rectocele is formed by a combination of factors: a herniation of the rectum through a defect
in the rectovaginal fascia as well as a lateral detachment of the level II support from the arcus
tendinous fasciae pelvis (ATFP).
o This can usually be seen as a visible bulge of the rectum through the posterior vaginal
wall; often associated with a deficiency and laxity of the perineum.
o This is the classical level III defect (posterior) affecting the perineal body.
 Enterocele is formed by a prolapse of the small bowel through the rectouterine pouch, the
pouch of Douglas, through the upper part of the vaginal vault.
o The condition may occur in isolation, but usually occurs in association with uterine
prolapse; may akso occur following hysterectomy when there is inadequate support
of the vaginal vault. This represents damage to level I support.

Uterine prolapse
 Descent of the uterus, which occurs when level I support is deficient, may occur in isolation
from vaginal wall prolapse but more commonly occurs in conjunction with it.
 First-degree prolapse of the uterus often occurs in association with retroversion of the uterus
and descent of the cervix within the vagina; If the cervix descends to the vaginal introitus, the
prolapse is defined as second degree.
 The term procidentia is applied to where the cervix and the body of the uterus and the vagina
walls protrude through the introitus and describes total or third-degree prolapse.
Symptoms and signs
 A sense of fullness in the vagina associated with dragging discomfort.
 Visible protrusion of the cervix and vaginal walls.
 Sacral backache is usually relieved on lying down.

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Urethrocele and cystocele

 Typically patients complain of ‘something coming down’ per vaginum.
 At times there may be incomplete emptying of the bladder and this will be associated with
double micturition- the desire to repeat micturition immediately after apparent completion of
voiding and patient may give a history of having to manually replace the prolapse into the
vagina to void.
 Some patients may get recurrent urinary tract infections as a result of incomplete emptying of
the bladder.
 Occasionally the patient may complain of occult stress incontinence, i.e. the involuntary loss
of urine following raised intra-abdominal pressure that is not readily demonstrable on
coughing but appears on reducing the prolapse.
 The diagnosis is established by examination in the dorsal position.
o A single bladed Sim’s speculum can be used to visualize the anterior vaginal wall.
o hen the patient is asked to strain, the bulge in the anterior vaginal wall can be seen
and often appears at the introitus.
Rectocele
 The prolapse of the rectum through the posterior vaginal wall is commonly associated with a
deficient pelvic floor, disruption of the perineal body and separation of the levator ani.
 It is predominantly a problem that results from over distension of the introitus and pelvic floor
during parturition.
 The symptoms of a rectocele include difficulty with evacuation of faeces with an occasional
need to ‘manually digitate’.
 Patients can complain of vaginal looseness and sexual dysfunction as a result of this.

Enterocele
 Herniation of the pouch of Douglas usually occurs through the vaginal vault if the uterus has
been removed.
 It is often difficult to distinguish between a high rectocele and an enterocele as the symptoms
of vaginal pressure are identical.
 Occasionally an examination in the standing position or a bidigital examination may reveal an
enterocele in a woman with no obvious signs of prolapse but complains of a dragging
sensation in the pelvis or a low backache.

Uterine prolapse
 Descent of the uterus is initially associated with elongation of the cervix and descent of the
body of the uterus; mostly the affected portion of the cervix is supravaginal.
 The symptoms are those of pressure in the vagina and, ultimately, complete protrusion of the
uterus through the introitus. At this stage, the prolapsed uterus may produce discomfort on
sitting, and decubitus ulceration may result in bleeding.
 UTI may occur because of compression of the ureters and consequent hydronephrosis due to
incomplete emptying of the bladder.

Staging/grading of prolapse Baden–Walker halfway system

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Pathogenesis of Prolapse may be:

 Congenital.
 Acquired
o The commonest form of prolapse is acquired under the influence of multiple factors.
o Predisposing factors include:
 High parity
 Raised intra-abdominal pressure
 Hormonal changes
Management
 Prevention:
o Good surgical technique in supporting the vaginal vault at the time of hysterectomy
reduces the incidence of later vault prolapse.
o Avoiding a prolonged second stage of labour and inappropriate or premature bearing
down efforts; encouraging pelvic floor exercises after delivery and the judicious use
of instrumental delivery with appropriately individualized episiotomies may all help
to reduce the risk of prolapse in later life.
 Conservative treatment:
o Minor degrees: Pelvic floor exercises.
o Hormone replacement therapy.
o The most widely used pessaries are:
 Ring pessary
 Hodge pessary: This is a rigid, elongated, curved ovoid which is inserted in a
uterine retroversion.
 Gelhorn pessary: This pessary is shaped like a collar stud and is used in the
treatment of severe degrees of prolapse.
 Shelf pessary: This is shaped like a coat hook and is used mainly in the
treatment of uterine or vaginal vault prolapse.

 Surgical treatment
o Fascial repairs.
o Graft repairs
o ‘Needle driven mesh kits’: PERIGEE™

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Topic 31: Urinary tract disorders in women (pp 348- 356)

Incontinence of urine
The involuntary loss of urine may be associated with bladder or urethral dysfunction or fistula
formation. Types of incontinence are listed below:
 True incontinence is continuous loss of urine through the vagina; it is commonly associated
with fistula formation but may occasionally be a manifestation of urinary retention with
overflow.
 Stress incontinence is the involuntary loss of urine that occurs during a brief period of raised
intraabdominal pressure.
 Urge incontinence is the problem of sudden detrusor contraction, with uncontrolled loss of
urine. may be due to idiopathic detrusor instability or associated with urinary infection,
diabetes or neurological disease
 Mixed urge and stress incontinence occurs in a substantial number of women.
 Overflow incontinence occurs when the bladder becomes dilated or flaccid with minimal or no
tone/ function.
 Miscellaneous types of incontinence include infections, medications, prolonged
immobilization and cognitive impairment.

Urinary frequency
 Urinary frequency is an insuppressible desire to void more than seven times a day or more
than once a night.
 If affects 20% of women aged 30-64 years, and can be caused by pregnancy, diabetes, pelvic
masses, renal failure, diuretics, excess fluid intake or habit, the most common cause is UTI .
 The frequency may be diurnal (daytime) or nocturnal.

Dysuria
This symptom results from infection. Local urethral infection or trauma causes burning or scalding
during micturition, but bladder infection is more likely to cause pain suprapubically after micturition
has been completed.

Urinary retention
Acute urinary retention is less of a problem in women. It can however be seen:
 after vaginal delivery and episiotomy
 following operative delivery
 after vaginal repair procedures (operations that involve posterior vaginal wall and perineum).
 in the menopause – spontaneous obstructive uropathy
 in pregnancy – a retroverted uterus may become impacted in the pelvis towards the end of
the first trimester
 when inflammatory lesions of the vulva are present
 as a result of untreated over-distension of the bladder (such as following delivery),
neuropathy or malignancy.

DIAGNOSIS
 Continuous loss of urine indicates a fistula, but not all fistulas leak urine continuously.
 The fistulous communication usually occurs between the bladder and vagina, vesicovaginal
fistula, and the ureter and vagina, ureterovaginal fistula.
 Fistula formation results from:
o obstetric trauma associated with obstructed labour
o surgical trauma
o malignant disease
o radiotherapy.
 There are other types of fistula with communications between bowel and urinary tract and
between bowel and vagina, but these are less common.
 Rectovaginal fistulas have a similar pathogenesis, with the additional factor of perineal
breakdown after a third degree tear. Urinary fistulas are localized by:

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o Cystoscopy
o intravenous urogram
o instillation of methylene blue via a catheter into the bladder.
 The bladder and urethra are assessed in the laboratory by urodynamics.
This procedure usually involves three basic steps:
o Uroflowmetry: The patient is asked to pass urine into a specially designed toilet that
measures voided volume, maximal and average urinary flow rates. Flow rates of >15
mL/sec are considered acceptable.
o The cystometrogram: Pressure is measured intravesically and intravaginally.
The volume of fluid in the bladder at which the first desire to void occurs is usually
about 150 mL; A strong desire to void occurs at 400 mL in the normal bladder.
o Urethral pressure profile: This is performed at the very end of the cystometry and
measures the pressure within the mid-urethra, in particular the maximum urethral
closure pressure (MUCP).

MANAGMENT
Urinary tract fistula
 In the developed world, most urinary tract fistulas, most commonly vesicovaginal or
ureteovaginal, result from surgical trauma at the time of hysterectomy, or sometimes
following caesarean section.
 The patient should be treated by catheterization and continuous drainage.
 If closure has not occurred after 2–3 months, the fistula is unlikely to close spontaneously, and
surgical closure is recommended.
Stress incontinence
 Stress incontinence should be managed initially by pelvic floor physiotherapy.
 Surgical treatment is indicated where there is a failure to respond to conservative
management.
 In the presence of anterior vaginal wall prolapse, anterior repair, with the placement of
buttressing sutures at the bladder neck, has the virtue of simplicity.
 The following procedures are commonly used Mid-urethral slings
o Tension-free vaginal tape (TVT™): Bladder neck elevation can be achieved by the
placement of a tension-free vaginal tape.
o Laparoscopic Burch colposuspension involves bladder neck elevation by suturing the
upper lateral vaginal walls to the iliopectineal ligaments under laparoscopic control.
o Transurethral injections: Injectable bulking agents can be injected via a cystoscope
into the mid-urethra. The commonest agents employed are collagen and silicon.
Drug treatment
 The alternative approach is to use anticholinergic drugs, act at the level of the bladder wall.
 Muscarinic receptors on the bladder wall and cause relaxation; some are more specific and
act on M3 receptors.
Pelvic floor physiotherapy: pelvic floor muscle training: In women who have mild to moderate
symptoms of urinary incontinence, pelvic floor muscle training (PFMT) also known as Kegel Exercises,
entails voluntary contraction of the levator ani muscles.
Electrical stimulation (interferential therapy) As an alternative/adjunct to active pelvic floor contraction,
a vaginal probe may be used to deliver low-frequency electrical stimulation to the levator ani muscles
used to improve either stress or urge incontinence.
Dietary modification: Patients are encouraged to avoid carbonated drinks and caffeine and commence
cranberry tablets because these often help with reducing symptoms of urgency and frequency.
Timed voiding: Patients are encouraged to void ‘by the clock’ in an attempt to limit the waves of
urgency that often patients with OAB symptoms experience.
Vaginal oestrogen. Oestrogen has been shown to increase urethral blood flow and increase alpha-
adrenergic receptor sensitivity, thereby increasing urethral coaptation and urethral closure pressure.

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The neuropathic bladder

 Loss of bladder function may be associated with a variety of conditions that affect the CNS.
These conditions may also be associated with alteration in bowel function, sexual dysfunction
and loss of function of the lower limbs.
 Presentation
o The neuropathic bladder is a reflection of dys-synergy between the activity of the
detrusor muscle and the bladder sphincter.
o This results in a variety of disorders ranging from the ‘automatic bladder’ through
retention with overflow at high or low pressure to total stress incontinence. It may
also be associated with renal failure.
 Etiology
o The causation may be suprapontine, such as a cerebrovascular accident, Parkinson’s
disease or a cerebral tumour.
o Infrapontine causes include cord injuries or compression, multiple sclerosis and spina
bifida.
o Peripheral autonomic neuropathies that affect bladder function may be idiopathic or
diabetic and, occasionally, secondary to surgical injury.
 Diagnosis
o The diagnosis is established by a systematic search for the cause involving
cystometry, urinary flow rate studies, neurological screening, brain scan, pyelography
and renal isotope scans.
 Management
o non-surgical management using absorptive pads and clean intermittent self-
catheterization.
o Anticholinergic drugs.
o Surgical treatment includes the use of artificial sphincters and sacral nerve
stimulators.

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