OBS&GYN

Gynecology
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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1. Anatomy of vulva and perineum (labeled diagram.), Blood supply, nerve supply and
lymphatic drainage of the vulva.
Anatomy
Definition :
Female external genitalia .









Parts :
1-Mons Pubis : (Mons veneris)
→ Suprapubic pad of fat covered by skin & hair.
→ Appears as a triangle with the base upwards .
2-Labia majora : (homologous to scrotum in males)
→ 2 skin folds covered by hair from outside only.
→ posteriorly : unite → post. commissure . Anteriorly : reach mons pubis.
→ Contains : fat ,hair, sebaceous glands ,sweat glands & Bartholin's gland (in post. 1/3) .
3-Labia minora : (homologous to penile urethra in males)
→ 2 non keratinized pigmented skin folds within the labia majora.
→ posteriorly : unite → post. fourchette . Anteriorly : prepuse & frenulum of clitoris .
→ Contains : erectile tissue , with no hair , sebaceous glands , sweat glands .
4-Clitoris : (homologous to penis)
→ The most sensitive area in female genital tract→ the principal orgasmic organ in female.
→ Attached to pubic arch by suspensory ligament .
→ Consists of
2 corpora (erectile cavernous bodies) covered by bulbospongiosus & ischiocavernosus.
Glans covered by prepuse & frenulum (derived from tissues derived from labia minora)
→ Rich in sweat glands & nerve supply .
→ Supply : Arterial → dorsal artery of clitoris.
Venous→ pudendal plexus.
Lymphatic → inguinal LNs + Cloquet LN.
→ Surgical importance :
-Main part removed in circumcision,so may affect woman's sexuality.
-Clitoriomegally occurs with hyperandrogenemia.
-Cloquet LN → external iliac → common iliac → para-aortic LNs.

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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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5-Vestibule :
→ Area surrounded by labia minora .
→ Contains the following openings : external urethral opening , skene' glands
(paraurethral glands) , external vaginal orifice , ducts of Bartholin's gland .
→ The bulb of vestibule: a flask shaped erectile tissue covered by bulbocavernosus
muscle → homologus to corpus spongiosum in male.
6-Hymen :
→ Thin layer of mucous membrane that closes the vaginal orifice .
→ It has opening for menstrual blood : annular , cribriform, bipartite , crescent .
→ Depression ( ) it & fourchette is called fossa navicularis .
7-Bartholin's gland :
→ 2 compound racemose glands lying in post. 1/3 of labia majora .
→ Their ducts open into the vestibule at 5 & 7 o'clock .
→ They produce mucoid material → lubricant for coitus .
8-Perineum :
→ The area ( ) vaginal orifice anteriorly & anus posteriorly .
→ Contains : skin ,S.C tissue ,superficial & deep perinii ,bulpospongiosus, pubococcygeus
→ Covers perineal body .

Blood supply :
Arterial : Internal & external pudendal arteries +Azygos artery of vagina.
Venous : to the plexus of the surrounding areas

Lymphatic drainage :
Superficial & deep inguinal L.Ns + Deep femoral L.Ns.

Nerve supply :
Pudendal N + Ilioinguinal nerve + Genital branch of genito-femoral N

[[
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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2. Development and relations , blood supply, nerve supply and lymphatic drainage of,
anomalies of vagina.(account). 
Development:
Origin : 1- Upper 4/5 → fused lower 1/3 of Mullerian duct .
2- Lower 1/5 → urogenital sinus .
Relations :
A-Anteriorly : → Upper 2/3 : the base of the bladder.
→ Lower 1/3: the urethra. 
B-Posteriorly: → Upper 1/3 : the peritoneum of Douglas pouch.
→ Middle 1/3 : the ampulla of the rectum.
→ Lower 1/3 : perineal body separating it from the anal canal .
C-Laterally : → Cardinal ligaments.
→ Pelvic cellular tissues (paracolpus) .
→ Levator ani and ischeorectal fossa.
→ Urogenital diaphragm (triangular ligament).
→ Vestibular bulb & bulbocavernosus muscle.
Blood Supply :
1.Arterial supply:
Upper part → Vaginal artery (arises directly from internal iliac or from uterine artery)
Lower part → middle and inferior rectal arteries, or vesical arteries
Cervicovaginal branch of the uterine artery → two azygos arteries (ant. & post.).
2.Venous drainage:
Upper part → drains to uterine vein and to internal iliac vein.
Lower part → drains to dorsal vein of the clitoris & middle rectal vein → pudendal vein.
Nerve Supply :
Upper part → as the cervix.
Lower part → as the vulva.
Lymphatic drainage:
Upper part → drain with the cervix.
Lower part → drains with the vulva.
Congenital anomalies :
1- Vaginal atresia → cryptomenorrhea .
2- Transverse vaginal septum → cryptomenorrhea .
3- Longitudinal vaginal septum.
 
   
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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3. Dimensions of the uterus, micro-anatomy (structure) of the uterus (body and cervix),
normal positions of the uterus, congenital anomalies of the uterus. Blood supply, nerve
supply and lymphatic drainage of the uterus .( account).
Dimensions : 1 X 2 X 3 inches in nullipara (Cavity is 7 cm from ext. os to the fundus) .
Micro-anatomy:
1-Uterus
A.Endometrium:
-Consists of : Epithelium : A single layer of cubical or low columnar ciliated epithelium
Glands : simple tubular endometrial glands that dips into myometrium
Stroma : between surface epithelium & myometrium .Contains spindle
cells , blood vessels & lymphatics .
-Differentiated into: Superficial compact layer → sheds with menstruation.
Middle spongy layer → sheds with menstruation.
Basal layer → for regeneration.
-Under the effect of ovarian hormones .
B.Myometrium: (Muscle Layer)
-Formed of three muscle layer :Outer longitudinal , inner circular & intermediate
interlacing fibers in criss-cross fashion. (surround blood vessels so, contraction →
compression of bl. vessels → controls bl. flow during menstruation & controls bleeding
during 3
rd
stage of labor).
C. Peritoneum :
-Anteriorly : covers the body of the uterus & is reflected on bladder dome
→ uterovesical pouch.
-Posteriorly : covers the body of the uterus & the supravaginal portion of the
cervix is reflected on the rectum → Douglas pouch (cul de sac)
-Laterally : forms the leaves of the broad ligament .
2-Cervix
1-Mucosa:
-Endocervix (cervical canal) → simple columnar epithelium .
-Ectocervix → squemous epithelium
-Transformation zone → area of transformation ( ) the two types.
→ at the external os , may be gradual or abrupt .
→ area of rapid proliferation → 90% of cancer Cx. in it.
-Cervix don't share in menstruation.
-May be estrogenic or progesteronic cervical mucous (see infertility) i.e, undergo cyclic
changes during menstrual cycle .
-PH 8.5 (alkaline)
2-Muscle layer : inner circular and outer longitudinal smooth muscle .
3-Adventitia : it has peritoneal covering only on the post. surface of its supravaginal portion .
Position of the normal uterus :
Normal uterus has:
1. A central position in the pelvic cavity.
2. Slight dextrorotation.
3. Anteverted.
4. Anteflexed.
5. The external os at the level of the ischial spine.

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Congenital anomalies :
Origin : fused middle 1/3 of the mullerian duct.
Anomalies
A-Mullerian agenesis : → Bilateral : Mullerian agenesis syndrome
→ Unilateral : unicornuate + rudimentary horn
B-Fusion defect :
No fusion (uterus didelphys) :
true didelphys: 2 uteri + 2 cervices + 2 vagina + 2 vulvae (very rare)
pseudo didelphys : 2 uteri + 2 cervices + 1 vagina with septum + 1 vulva .
Incomplete fusion : Bicornic bicollis : 2 uteri +2 cervices +1 vagina
Bicornis unicollis (Bicornuate) : 2 uteri +1 cervix
Arcuate uterus
Bicornuate with rudimentary horn
C-Failure of septum resorption : Septate → complete septum
Subseptate → incomplete septum
D-Hypoplastic uterus : Fetal
Infantile → cx. : body ratio 2 :1
Pubescent → cx. : body ratio 1 :1

Blood Supply :
1.Arterial supply: Uterine artery.(Cervix → circular & descending branches . )
2.Venous drainage: Uterine & hypogastric veins .

Nerve Supply :
- Corpus is only sensitive to distension & insensitive to touch , pain , cutting & freezing
- The nerve supply is autonomic (sympathetic or parasympathetic).
Sympathetic supply: → T5-T6(mainly motor) & from T10 to L2 (mainly sensory → Pain)
→ produces muscular relaxation and vasoconstriction.
Parasympathetic fibers: → Derived from S2, S3 and S4
→ Produce muscular contraction and vasodilatation
- Cervix is only sensitive to dilatation & insensitive to touch , pain , cutting & freezing .
Lymphatic drainage
A-Cervix :
Anteriorly : to the obturator lymph nodes & external iliac group.
Posteriorly : to lateral sacral group via the uterosacral ligaments.
Laterally : to parametrial & hypogastric lymph nodes.

B-Corpus :
Upper part: → mainly : ovarian lymphatics → para-aortic lymph nodes .
→ small part : lymphatics of the round ligaments → inguinal LN..
Middle part: to hypogastric lymph nodes.
Lower part: as the cervix .
 
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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4. Clinical disorders associated with congenital anomalies of the uterus.( account).
These Disorders are :
1- Infertility → e.g, aplsia or hypoplasia .
2- Recurrent abortion → e.g : septate uterus , bicornuate uterus .
3- Ectopic Pregnancy
4- Preterm labor
5- Malpresentation
6- Dysmenorrhea
 
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5. Ligaments attached to the body of the uterus. Ligaments attached to the cervix uteri.
(account).
Ligaments attached to the body of the uterus:
1. Broad Ligament:

Def. : It is a double fold of peritoneum

Position :
-Extends from the uterine tube above to the pelvic floor below,
-Extends from the uterus medially to the pelvic wall laterally.
-Its lateral border forms the infundibulopelvic ligament containing the ovarian vessels.
-The mesovarium of the ovary is attached to the post. layer of the broad ligament

Contents :
1. Fallopian tubes : in its free upper border.
2. Ligaments : → Round ligament: below and in front the Fallopian tube.
→ Ovarian ligament: below and behind the Fallopian tube.
→ Mackenrodt's ligaments in its lower end attached to the cervix.
3. Ureter : terminal part of the behind its lowermost end.
4. Blood vessels : uterine & ovarian vessels & anastomosis between both .
5. Nerves : ovarian nerves and paracervical nerves.
6. Lymphatics : drainage of the uterus and along the round ligament.
7. Vestigeal remnants : Gartener's duct, epoophron, paroophron
(remnants of mesonephric or Wollfian duct).

2. Round Ligament:

Def. : A fibrous cord running between the layers of the broad ligament (about 12 cm long).

Attachment :
Medial attachment: cornue of the uterus .
Lateral attachment: to the labium majus.

Coarse :
-Crosses the psoas muscle and the external iliac artery and vein → hooks round the
inferior epigastric artery → the internal inguinal ring → the inguinal canal→ the
external inguinal ring and breaks up into strands in the labium majus.

Clinical importance:
a. Aids in maintaining normal uterine position.
b. May be used by many surgical procedures in correcting RVF.
c. Steady the uterus in pregnant women and with uterine contractions.
d. If hypertrophied during pregnancy → inguinal pain.
e. As it passes in the inguinal canal; it may cause inguinal hernia or hydrocele.
f. In the fetus the round ligament is surrounded by a tube of peritoneum(the processus
vaginalis . If it remains patent, it is called the canal of Nuck, a rare site of a hernia.

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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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Ligaments attached to the cervix uteri:
1. The transverse cervical ligament : (Mackenrodt's or the cardinal ligament)
• From : the lateral aspect of the cervix and upper vagina.
• To : the lateral pelvic wall.
• The main ligament. Fan shaped & is related laterally to uterine artery & ureter.
2. Pubocervical ligament :
• From : the front of the cervix and upper vagina
• To : the bodies of pubic bones.
• On its reflection on the lower end of the bladder it units with Mackenrodt's
ligament to for a strong support to the bladder known as bladder pillars.
3. Uterosacral ligament:
• From : the back of the cervix and upper vagina
• To : the 2nd piece of the sacrum.
• Pull the cervix backward → maintain AVF position of the uterus .
 
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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6. -Fallopian tube: development, anatomy, blood supply.( account).
Development:
Origin : upper 1/3 of the mullerian duct .
Congenital anomalies :
1- Aplasia .
2- Hypoplasia : ↑ incidence of ectopic pregnancy .
3- Diverticulum .
4- Accessory osteum .
Anatomy:
Definition : Musculo-membranous canal arising from cornue of uterus to the ovary .
Parts & measurements :
Length : 10 cm .
Parts : → interstitial (intramural) part: shortest & narrowest part 1.5 cm
→ isthmus : 2-3 cm
→ ampulla : longest & widest part 5-6 cm
→ infandibulum (fimbrial end) : has an abdominal ostea & surrounded by fimbriae

Relations :
-Runs in the free border of the broad ligament .
-The mesosalpnix encloses the tube completely except along its inferior aspect.

Blood supply:
Supply :
1.Arterial supply : medial 2/3 → Uterine artery .
Lateral 1/3 → ovarian artery .
2.Venous drainage : to corresponding veins .
 
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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7. Ovary: development, anatomy, blood supply and lymphatic drainage.( account).
Development:
Origin : Stroma (cortex & medulla) → mesodermal origin .
Germ cells → yalk sac
Surface epithelium , follicular cells → genital ridge.
Descent : ovaries are first in thoracic region then descend to pelvis by gobernaculum
(fibromuscular fold ) connecting the ovaries superiorly to labia majora inferiorly .
Congenital anomalies :
1- Gonadal agenesis or hypoplasia .
2- Gonadal dysgenesis : Turner's syndrome , Sweyer's syndrome.
Anatomy:
Definition : Female gonads responsible for production of ova & hormones .
Parts & measurements :
Length : about 3-5 Cm X 2.5 cm X 1.5 cm and 5-10gms in weight .
Parts : The ovary is formed of hilum, cortex and medulla.
1-Hilum: via which the blood vessels, nerves and lymphatics pass to & from ovary.
2-Cortex : the peripheral active part of the ovary.
It contains : Fibrous tissues + epithelial elements + Graffian follicles .
3-Medulla: it is the central core formed mainly of fibrous tissues.
Shape : almond shaped .
Position : → lies in ovarian fossa (fossa ovaries) .

Relations : (the only intra-abdominal organ which is not covered by peritoneum)
Anteriorly : fallopian tubes, bladder dome and uterovasical pouch.
Posteriorly : the ureter is crossing in front of internal iliac artery.
Upper pole : attached to pelvic wall by infandibulo-pelvic ligaments .
Lower pole :attached to cornue of uterus by ovarian ligament .
Relations of the ovarian fossa
Anteriorly : the obliterated umbilical artery.
Posteriorly : the internal iliac artery and the ureter.
The floor is formed by: The obturator internus muscle +Obturator vessels & nerves.

Supports : Infandibulo-pelvic ligament → to lateral pelvic wall .
Ovarian ligament → to uterus .
Mesovarium → to posterior leaf of broad ligament.
Blood supply:
1.Arterial supply : ovarian arteries (arising from aorta) which reaches ovaries via
infandibulo-pelvic ligaments .
2.Venous drainage : ovarian veins → Rt. : drains into IVC .
→ Lt. : drains into left renal vein.
Lymphatic drainage :
to paraaortic LNs
 
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8. Pelvic diaphragm, Levator ani: attachments , action. Anatomy of perineal body. (account).
Pelvic diaphragm or Pelvic floor is composed of muscle fibers of the Levator ani, the Coccygeus,
and associated connective tissue which span the area underneath the pelvis.

Levator ani:
Attachments:
Origin : → The posterior aspect of the body of the pubis.
→ The white line (thickened endopelvic fascia on the obturator internus muscle).
→ The ischial spine.
Insertion : Each levator ani muscle runs backwards and medially to blend in the midline
with the muscle of oposite side.
Action (Functions ):
1. Strong support of the pelvic organs.
2. Sphincteric action to the urethra, vagina and anal canal.
3. It relaxes during evacuation of the bladder & bowel.
4. Internal rotation of the fetal head during labor.

Coccygeus
is a muscle of the pelvic wall (i.e. peripheral to the pelvic floor), located posterior to levator ani and anterior to the
sacrospinous ligament.
Attachments:
Origin : arising by its apex from
1. The spine of the ischium
2. sacrospinous ligament
Insertion : inserted by its base into
1. The margin of the coccyx
2. Into the side of the lowest piece of the sacrum.
Action (Functions ):
1. It assists the Levator ani and Piriformis in closing in the back part of the outlet of the pelvis.
2. Pulls coccyx forward after defecation.

Anatomy of perineal body:
Def. : It is a pyramidal-shaped fibromuscular mass.
Position : Its base lies downwards, separating the vulva and lower vagina from the anal canal.
Structure :-The pubococcygeus muscles of the levators ani.
-The central tendon of the perineum:
a. The transverse perineal muscles, superficial and deep.
b. The external anal sphincter.
c. The bulbo-cavernosus muscle.
d. The posterior border of the urogenital diaphragm.
 
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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9. Imperforate hymen: symptoms, signs, treatment.( account).
Defined as Failure of breakdown ( ) vaginal plate & urogenital sinus .
Symptoms :
→ 1ry amenorrhea . (no menstruation till age of 16 with 2ry sex characters)
→ cyclic lower abdominal colicky pain & heaviness
→ acute retention of urine
→ If blood is infected : FHMA
Signs :
General → 2ry sex characters .
Abdominal → pelviabdominal swelling (hematometra or full urinary bladder) .
Local → only vulval inspection : bluish hymen , bulging, completely closed .
→ PR : hematocolpos + hematometra .
Inv. : US → full vagina & uterus by blood .
IVP → to detect associated UT abnormalities .
TTT : Hymenotomy +virginity certificate (in governmental hospital + antibibiotics +
aseptic conditions → cruciate or crescent incision +trimming of the edges)

 
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10. Characters of normal menstruation. (MCQ).
Characters :
1-Duration : 2-7 days (average 5 days).
2-Amount : 30 – 80 ml (average 50 ml) → 80% occur in 1
st
days .
3-Odour : offensive .
4-Colour & clots : dark red color (acid hematin) + no clots (fibrinolytic system) .
(severe bleeding → fresh red + clots)
11. Proliferative phase of endometrium: hormonal control and M/E. Secretory phase of
endometrium: hormonal control and M/E. (MCQ).
Proliferative phase
Def. : phase of building up of endometrium under estrogenic effect.
Timing : from end of bleeding till day 14 (in 28 day cycle) .
Changes : M/E
a-Endometrial glands : straight narrow short → long & tortuous & ↑ No. of mitotic cells
Epithelial lining : Low columnar → pseudostratified columnar .
b-Stroma : dense & compact + infrequent vascular structures .
Thickness of endometrium : early in this phase 1-2 mm only basal compact layer.
Secretory phase
Def. : phase of thickening & ripening of endometrium under progesterone effect.
Timing : last 14 days of the cycle (in 28 day cycle) .
Changes : M/E
a-Endometrial glands : tortuous + filled with secretions in the lumen + subnuclear glycogen
containing vacules .
b-Stroma : edema + arteries become spiral long & coiled .
Thickness of endometrium : late in this phase 4-8 mm & is differentied into
Superficial compact layer + Middle spongy layer + deep compact layer .
12. Mature Graafian follicle: labeled diagram, function, fate. .(MCQ)
Labeled diagram
Structure of mature Graafian follicle :
→ Ovum
→ Perivettine space
→ Zona pellucida
→ Corona radiata
→ Cumulus oophorus (group of granulosa cells
attaching CR to wall of follicle)
→ Follicular cavity
→ Granulosa cells
→ Theca interna cells
→ Theca externa cells
Function:
 G-cells → estrogen production
 Theca cells → Androgen production
Fate:
 Ovulation
 C.L
 
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13. Cyclic changes in cervical mucus. (MCQ).
1. Estrogenic cervical mucus (↑amount, ↓ viscosity, ↓ cellularity , +ve Spinnbarkiet , +ve Ferning , +ve
elastic recoil)
2. Progestational cervical mucus (↓amount, ↑viscosity ,↑ cellularity , -ve Spinnbarkiet , -ve Ferning ,
-ve elastic recoil)

14. Normal puberty: definition , age and signs. (MCQ).
Definitions :
-Puberty :It is the period of life during which 2ry sex characters develop , sex organs mature
→ the reproductive capacity is attained.
-Menarche : 1
st
menstrual flow .
-Adolescence : It is the physiologic , social , behavioural and personal independence →
development of adult identity(a broader term than puberty).
Average age : 10 – 16 years .
Signs (Pubertal changes)
A-Changes :
1-Physical changes : Action of estrogen except in pregnancy . (ﺐﺘﻜﺗ)
2-Psychological changes :
-The girl become shy & refuses parental control + tendency to other sex (sex urge)
B-Sequence of events :
1-Growth spurt: It passes in 3phases:
a. Minimum growth velocity: 5 cm per year.
b. Peak height velocity: 8.5 cm per year.
c. Stage of decreased velocity.
2-Thelarche (breast development):
-Usually appears at about the age of 9 to 11 years & completed over 3 years.
3-Adrenarche: (development of axillary and pubic hairs)
-Due to production of 17 ketosteroids, DHEA and DHEAS from adrenal glands.
4-Menarche:. Affected by many factors, such as : Socio-economic factors, environmental
factors , racial and geographical factors. Medical & endocrinal diseases (accelerates
puberty): Blindness, deafness & DM .
-In Egypt, usually occurs around 12.5 Y
 
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15. Menopause: definition, age and types. Changes associated with menopause (general, local.
hormonal). Symptoms of menopause. Hormonal and non-hormonal therapy of menopause.
Postmenopausal osteoporosis (bone changes with menopause, symptoms, bone density
imaging and treatment).( account).
Definitions :
-Menopause : permanent cessation of menstruation > 12 months due to complete depletion
of primordial follicles .
-Climacteric : period of life in w' female is changed from reproductive to non reproductive
state (menarche to puberty is like menopause to climacteric) .
-Postmenopausal period : period of life after cessation of menstruation .
-Perimenopausal period : 5 years around the average age of menopause .
-Premenopausal period : from 40 y to beginning of perimenopausal period .
Average age : 40 – 55 years with average 51 years .
Types :
1. Natural menopause .
2. Premature menopause : <40 Y (due to premature ovarian failure) .
3. Delayed menopause : menopause > 55 y
4. Induced menopause : → Surgical menopause : surgical removal of ovaries.
→ Radiological menopause : irradiation of ovaries.
→ Chemotherapy for ttt of malignant tumors .
Menopausal changes :
General :
-Psychological : anxiety , depression.
-Breasts : atrophic .
-Osteoporosis.
-Hot flushes.
-↑ LDL & ↓ HDL → ↑ atherosclerosis & CVS ischemia .
Hormonal changes :
-FSH : ↑ (>40 IU)
-Estrogen : ↓ E2 , relative ↑ of E1 .
-Progesterone : marked ↓ .
-Androgen : relative ↑ .
-Hypothyroidism.
Local (Genital) changes :
-Vulva : atrophy & narrow introitus .
-Vagina : ↓ vaginal acidity + atrophic vagina .
-Cervix : ↑ incidence of ulcers ectropion & erosions .
-Uterus : small atrophic + atrophic endomemtrium .
-Ovaries : small atrophic .
-Pelvic ligaments : lax → ↑ incidence of prolapse & stress incontinence .

 
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Symptopms :
1-Specific symptoms:
1.Vasomotor: (the most characteristic symptom)
-Hot flushes over the chest, neck and face followed by profuse sweating
-They can last for few seconds up to 30 minutes and may occur at night disturbing sleep.
2.Osteoporosis .
3.Nervous and psychological:
-Palpitation , dizziness, headache, sleep disturbances, anxiety, irritability, mood changes,
depression& lack of concentration.
4.Gastrointestinal : constipation and abdominal distension.
5.Urinary : frequency, dysuria, stress incontinence and predisposition to UTI .
6.Genital : Dyspareunia , hirsutism & uterine prolapse.
2-Non specific symptoms:
- headache, insomnia, depression, psychological, social and memory changes.
Hormonal replacement therapy : (HRT)
Forms & roote :
-Estrogen e.g, ethinyl estradiol estradiol valerate , conjugate equine estrogen (not given
alone except in hystroctomized patients, otherwise E & P are given).
-Progesterone : gestagens
A-Oral : (under hepatic 1
st
pass metabolism)
-Sequential regimen : EE2 for 2 w , then add primolut for 10 days → withdrawal bleeding
(in 80% of cases)
-Combined regimen : Daily continuous estrogen & progesterone → allow the use of
small dose of gestagen less bloating , wt. gain & mastodenia +
prevent end. hyperplasia .
B-Non oral : (avoid hepatic 1
st
pass metabolism)
-Cutanious : skin patches (e.g, Estraderm patches) & estrogen gel .
-Vaginal : vaginal cream or ring .
-IM : estrogen & progesterone .
Indications : → Symptomatic menopausal women to relieve menopausal symptoms.
→ Premature or induced menopause.
→ To prevent osteoporosis for a minority of women with one or more risk factor.
Contraindications :
A-Absolute : → Thromboembolic disease. → IHD
→ genital system or breast cancer →family history of these cancers .
→ hepatitis .
B-Relative : → uterine fibroids & endometriosis..
→ migrane .

Benefits : → relieve menopausal symptoms. → prevent genital atrophy & osteoporosis
→ ↓ risk of developing cancer colon → ↓ risk of developing Alzheimer .

Risks : → ↑ incidence of cencer breast . → ↑ incidence of endometrial carcinoma .
→ ↑ risk of thromboembolic diseases .
How to ↓Risks : → smallest dose of estrogens . → add cyclic progesterone .
→ avoid long term use of HRT. → use alternatives & phytestrogens
Follow up : → Periodic mammography . → PAP smear yearly .
→ Bone densitometry. → endometrial assessment in AUB
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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Non-Hormonal therapy:
A- Reassurance & psychotherapy .
B- General : Ca , sedatives , minerals & vitamins .

Postmenopausal Osteoporosis
Definition : ↓ bone mineral density (BMD) by > 2 standard deviation from the normal.
(Osteopenia : ↓ of BMD between 1-2 SD from the normal)

Incidence: By the age of 60, 25% of women develop spinal compression and fractures.

Risks: The resistance to fractures is decreased in women with osteoprosis.

Sites of affection: Common sites are: vertebrae , femoral neck , distal radius , calcanium.
→ curvature of the spine , fracture neck femur , ↓ height .

Risk factors : 1-Race: white women > blacks. 2-Early menopause.
3-↓ weight for height. 4-Sedentary life.
5-Smoking, high caffeine (coffee, tea). 6-High protein & low calcium diet.
7-Drugs like heparin or corticosteroids and alcohol intake.

Diagnosis : By bone densitometry.

Treatment
1- (HRT) at the onset of menopause.
2- Regular exercises,stop smoking, coffee, tea and alcohol intake.
3- Calcium supplementation and decrease proteins intake.
 
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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16. Estrogen : structure, sites of endogenous secretion, control of secretion, biological
functions, clinical uses, side effects and complications.( account).
Structure
-Steroid hormone→ 18 C (cyclo pentano phenatherine group)
Sites of endogenous secretion
1-The ovary .
2-Syncitiotrophoblast of the placenta.
3-Adrenal cortex (small amount).
4-Peripheral adipose tissue (small amount).
Control of secretion
 F.S.H → ++estrogen production from granulosa cell
 L.H → ++estrogen production from C.L
 estrogen → -ve feed back è F.S.H
→ +ve feed back è L.H
Biological functions
I-On the genital system :
a-Vulva : (++) growth of labia majora & minora .
b-Vagina: → shift to Rt. in maturation index i.e,
predominant superficial cell type → acidophilic
cells with pyknotic nuclei on clear background.
→ proliferation of vaginal epithelium
→ (++) Droderline's bacilli → ↑ vaginal acidity
c-Cervix : estrogenic cervical mucous (↑amount, ↓ viscosity,
↓ cellularity , +ve Spinnbarkiet , +ve Ferning , +ve
elastic recoil)
d-Uterus : proliferative endometrium
(if unopposed → end. hyperplasia → end. carcinoma)
e-Tubes : ↑ motility & vascularity .
IV-General action :
Breast : ↑ proliferation of duct system & ↑ vascularity
Bone & joints : ↑ bone mineralization .
GIT : ↑GIT motility
Clotting : ↑ clotting →↑ clotting factors II , VII , IX , X
→↓ fibrinolytioc activity
Met. : Prt. : anabolic CHO : diabetogenic effect
Fat : ↑ HDL & ↓ LDL H20 : salt & H2o retention
III-During pregnancy :
→ ↑ size & ↑ vasculartiy of the genital organs.
→ contraction of uterus .
→ On breast : development of duct system.
IV-Central action :
→ (-ve) feed back with FSH → (+ve) feed back with LH
V-2ry sex characters : HBV
-Feminine Hair distribution .
-Feminine Body configuration : well developed breasts,
broad pelvis , feminine fat distribution
-High pitched Voice .
VI-Growth spurt .
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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Clinical uses
Combined estrogen & progesterone
1-Disorders of mens. : amenorrthea , dysmenorrhea , DUB
2-Menopauasal symptoms : hot flushes , osteoprosis
3-Contraception
4-Infirtility

Estrogen only
Disorders of vagina & vulva vulvovaginitis in children
Senile vaginitius trophic ulcers in post menopausal prolapsed

Side effects
Hyper-estrogenic state
Causes :
-Physiological → early menarche
→ late menopause
→ Nullipara & low parity
-Pharmacological → ERT
-Pathology → estrogen secreting ovarian tumor
→ metropathia hemorrhagica
→ PCO
-Biochemical → cancer corpus triad (DM , HTN , obesity)
Complications
Hyper-estrogenic state predispose to the following conditions :
1. Uterine fibroids
2. Endometriosis
3. Endometrial hyperplasia
4. Endometrial carcinoma
5. Cystic mammary hyperplasia of the breast
6. Cancer breast .

   
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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17. Progesterone: structure, sites of endogenous secretion, biological functions and clinical
uses. ( account).
Structure
-Steroid hormone → 21 C (cyclo pentano phenatherine group)
Sites of endogenous secretion
1-Corpus luteum.
2-Syncitiotrophoblast of the placenta.
3-Adrenal cortex (small amount).
4-Stroma cells of the ovary (small amount) .

Biological functions
Action is present only in organs previously primed by estrogen
I-On the genital system :
-Vagina : → Shift to middle in maturation index i.e,
predominance of intermediate cell type →
basophilic cells with vesicular nuclei on clear
background.
b-Cervix : progestational cervical mucous(↓amount, ↑viscosity
↑ cellularity , -ve Spinnbarkiet , -ve Ferning , -ve
elastic recoil)
c-Uterus : secretory endometrium
(it must be estrogen primed endometrium)
d-Tubes : ↓ motility .
II-General action :
Breast : development of acini
Bone & joints : relaxation of joints & ligaments .
GIT : ↓ GIT motility
Met. : Thermogenic effect ↑ body temp. o.5 º
Fat : ↓ HDL & ↑ LDL H20 : salt excretion .
III-During pregnancy : (hormone of pregnancy)
→ Prepare endometrium for implantation & maintain decidua
→Relaxation of uterus and other smooth muscles
→On breast : development of alveolar system.
IV-Central action :
→ (+ve) feed back with FSH
→ (+ve) feed back with LH in small doses
→ (-ve) feed back with LH in large doses
Clinical uses
Combined estrogen & progesterone
1-Disorders of mens. : amenorrthea , dysmenorrhea , DUB
2-Menopauasal symptoms : hot flushes , osteoporosis
3-Contraception
4-Infirtility

Progesterone only
Endometriosis
Endometrial hyperplasia
 
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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18. Indications of combined estrogen and progesterone therapy.( account).
1-Disorders of mens. : amenorrhea , dysmenorrhea , DUB
2-Menopauasal symptoms : hot flushes , osteoporosis By (HRT) حﺮﺸﺗ
3-Contraception ( Contraceptive uses of COC's)
→ in females 20 -35 years if not contraindicated .
4-Non-Contraceptive uses of COC's
1-DUB. 2-Endometriosis.
3-Spasmodic dysmenorrhea. 4-PMS.
5-Hairsuitism 6-Acne.
7-Functioning ovarian cyst 8-To postpone menstruation .
4-Infirtility
Hormonal replacement therapy : (HRT)
Forms & roote :
-Estrogen e.g, ethinyl estradiol estradiol valerate , conjugate equine estrogen (not given
alone except in hystroctomized patients, otherwise E & P are given).
-Progesterone : gestagens
A-Oral : (under hepatic 1
st
pass metabolism)
-Sequential regimen : EE2 for 2 w , then add primolut for 10 days → withdrawal bleeding
(in 80% of cases)
-Combined regimen : Daily continuous estrogen & progesterone → allow the use of
small dose of gestagen less bloating , wt. gain & mastodenia +
prevent end. hyperplasia .
B-Non oral : (avoid hepatic 1
st
pass metabolism)
-Cutanious : skin patches (e.g, Estraderm patches) & estrogen gel .
-Vaginal : vaginal cream or ring .
-IM : estrogen & progesterone .
Indications : → Symptomatic menopausal women to relieve menopausal symptoms.
→ Premature or induced menopause.
→ To prevent osteoporosis for a minority of women with one or more risk factor.
Contraindications :
A-Absolute : → Thromboembolic disease. → IHD
→ genital system or breast cancer →family history of these cancers .
→ hepatitis .
B-Relative : → uterine fibroids & endometriosis..
→ migrane .

Benefits : → relieve menopausal symptoms. → prevent genital atrophy & osteoporosis
→ ↓ risk of developing cancer colon → ↓ risk of developing Alzheimer .

Risks : → ↑ incidence of cencer breast . → ↑ incidence of endometrial carcinoma .
→ ↑ risk of thromboembolic diseases .
How to ↓Risks : → smallest dose of estrogens . → add cyclic progesterone .
→ avoid long term use of HRT. → use alternatives & phytestrogens
Follow up : → Periodic mammography . → PAP smear yearly .
→ Bone densitometry. → endometrial assessment in AUB
 
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19. FSH: structure, sites of endogenous secretion, biological function and clinical uses.
( account).
Structure
α-subunit : 92 AA
β-subunit : 118 AA
Sites of endogenous secretion
Basophil cells of anterior pituitary
Biological functions
1-Growth, ripening , maturation of the ovarian follicles
2-(++) aromatase activity of granulosa cells → production of estrogen
3-With LH → ovulation .
4- (++) formation of LH receptors.

Clinical uses
TTT of anovulation & hypogonadotrophic amenorrhea (extracted from urine of postmenopausal ladies → human
menopausal gonadotrophins (HMG) given IM
20. LH: structure, sites of endogenous secretion, biological functions and clinical uses.
( account).
Structure
α-subunit : 92 AA
β-subunit : 121 AA
Sites of endogenous secretion
Basophil cells of anterior pituitary
Biological functions
1-With FSH → ripening of the ovarian follicles
2-(++) androgen synthesis by theca cells
3-LH surge → ovulation .
4-(++) corpus luteum → est. & prog.

Clinical uses
TTT of anovulation & hypogonadotrophic amenorrhea (extracted from urine of postmenopausal ladies → human
menopausal gonadotrophins (HMG) given IM

 
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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21. Differential diagnosis of spasmodic dysmenorrhea and congestive dysmenorrhea
regarding: age, parity, pain characters, associated symptoms (table). Non surgical
treatment of spasmodic dysmenorrhea. Causes of congestive dysmenorrhea.
Premenstrual tension (syndrome): definition, age, symptoms and treatment.( account).
Differential diagnosis of spasmodic dysmenorrhea and congestive dysmenorrheal :


Non surgical treatment of spasmodic dysmenorrheal
*Prophylactic :
1. Health education
2. Psychotherapy
3. Reassurance

*Active Medical ttt :
A-Non hormonal : Anti-Pgs
→ e.g,ibuprofen,mephenamic a
→ ↓ endometrial PGs
→ started before pain & continued for few days
→ effective in 80 % of cases
B-hormonal : COCs → (--) ovulation (anovulatory cycles are painless)
→ 90 % cure

Causes of congestive dysmenorrhea :
1. Simple : constipation & coitus interuptus
2. Pathological: causes of pelvic congestion
3. Cong. : imperforate hymen
4. Inf. : PID , chronic cervicitis
5. Traumatic : IUD
6. Neoplastic : all neoplasms
7. Others : prolapse , endometriosis .
 

Spasmodic Congestive
Synom
-1ry dysmenorrhea, idiopathic (no cause) - ( has a cause).2ry dysmenorrhea
Parity
-Nullipara , after puberty. -Multipara , after marriage.
Age
-1
st
day of menstruation , relieved by
end of menstruation.
-Premenstrual period & relieved by
menstruation .
Pain Ch'
-Colicky , intermittent . -Dull aching .
-Suprapubic area referred to thighs. -Lower abdomen referred to back.
Associated
Symptoms
-Associated with nusea , vomiting ,
diarrhoea , headache & PMS
-Associate with other pelvic congestive
symptoms e.g, dysparonea, leukorrhea .
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Premenstrual tension (syndrome)

Definition
-Cyclic, physical, psychological, and behavioral symptoms before menstruation , sufficient
to cause distress and interferes with normal daily activities.
Age (Incidence):
-80% of women report premenstrual symptoms and the symptoms are severe enough to
interfere with daily activity in 5% -10% .
-Most common in women between 25 to 44 years.
symptoms
1-Physical symptoms: (in 40%) : → Facial and peripheral edema.
→ Breast tension.
→ Abdominal distention, bloating or weight gain.
→ Headache.
2-Psychological symptoms: (in 80%) →Tension. → sleep disturbance
→ Irritability. → lipido changes
→ Anxiety. → poor concentration
→ Depression. → changes in appetite
3-Behavioral symptoms: (in 20%) → Suicidal tendency & attempts.
→ Criminal behavior.
Treatment of PMS :
Physical symptoms are treated by :
1-Diuretics
2-COCs : It should not be used if mood symptoms are the primary ones.
3-GnRH agonists.
4-Bromocryptine
Psycho-behavioral symptoms are treated by:
→ Councelling → Tranquilizers.
→ Selective serotonin uptake inhibitors . → Vitamin B6
→ Progesterone. → Evening primrose oil.
→ Drugs that act on the y-aminobutyric acid receptor complex (benzodiazepin
Rarely: In severe and resistant cases proved by GnRh test, the definitive treatment is
abdominal hysterectomy and bilateral salpingoophrectomy.
 
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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22. Primary amenorrhea: causes, investigation (history, exam, special investigations).
( account).
Causes :
1. Cryptomenorrhea (Congenital Causes)
→ Imperforate hymen
→ Transverse vaginal septum
→ Vaginal atresia
→ Cervical atresia
2. Hypothalamic causes
1) Congenital : aplasia or hypoplasia Pituitary causes
2) Traumatic : fracture base of the skull.
3) Inflammatory : meningitis , encephalitis .
4) Neoplastic : intracranial tumor causing destruction of the hypothalamus .
5) Post irradiation .
6) Syndromes :
a-Frolich's syndrome :
1ry amenorrhea + hypogonadism + obesity(fat)
b-Laurance-Moon-Biedle syndrome : as Frolich's +
Limb defect → polydactly
Mental retardation
Blindness
c-Kallmann syndrome :
1ry amenorrhea + anosmia + Color blindness .

3. Ovarian causes
1) Congenital : aplasia or hypoplasia
2) Traumatic : fracture base of the skull.
3) Inflammatory : meningitis , encephalitis .
4) Neoplastic : Pituitary tumors
a-craniophryngioma : → arises from remnants of Rathke's pouch
→ compression on pituitary stalk & may lead to blurring of vision
→ TTT : surgery
b-Adenoma : → may be microadenoma or macroadenoma .
→ Most common are:Non functioning adenoma : usually surveillance
is sufficient prolactinoma→ amenorrhea & galactorrhea
(Frobes-Albright syndrome) .
→ TTT : dopamine agonist therapy
Surgery
Radiotherapy
5) Post irradiation .
6) Syndromes :
Delcastello syndrome : (any cause other than delivery)
-1ry amenorrhea & galactorrhea + 2ry infirtlity + 2ry genital atrophy
Levi Lorian syndrome :(pituitary infantilism)
C/P : amenorrhea , hypogonadism & short stature .
 
Before Puberty 
Before Puberty 
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4. Ovarian causes
1-Congenital :
a-Gonadal agenesis :
Karyotype : 46 XY
Cause : testes are functioning & secrete MIF → (--) female internal genitalia , then
testes vanishes or disappear due to unknown cause .
b-Gonadal dysgenesis : streak gonads
Pure gonadal dysgenesis :
- Failure of germ cells to migrate to the ovary → streak gonads .
- Karyotype : 46 XX
Sweyer syndrome :
- Failure of germ cells to migrate to the gonad → streak gonads .
- Karyotype : 46 XY
- 1ry amenorrhea & lack of sexual development .
Turner's syndrome
Incidence : 1/2000 live births .
Cause : oogonia migrate to genital ridge , but soon undergo degeneration .
Phynotype : underdeveloped female .
Karyotype : 45 X0 (may be mosaic 45 X0/46 XX or 45 X0/46 XY )
Gonads : streak ovaries (ridge of fibrous tissue)
C/P **Genital: underdeveloped female (no 2ry sex characters , underdeveloped ext.
genitalia ) + 1ry amenorrhea + infertility .
**Extra-genital → Short stature. → 10% are mentally retarded .
→ Sheild shaped chest with widely separated nipples. → Webbed neck .
→ Associated cardiac anomalies . → associated limb anomalies e.g, polydactly .
c-Triple X & super female :
Phynotype : female .
Karyotype : 47 XXX (triple X) , 48 XXXX (super female )
Gonads : ovaries.
C/P → amenorrhea , hypogonadism may be MR
2-Traumatic : Bilateral oophorectomy.
3-Inflammatory : mumps , TB .
4-Neoplastic : androgen secreting ovarian tumor .
5-Post irradiation .
6-Enzymatic deficiency : → galactosemia
→ 17 α hydroxylase deficiency
→ aromatase deficiency
7-Syndromes :
Resistant ovary syndrome : (savage syndrome)
-Defect in receptors of FSH & LH .
-C/P : 1ry amenorrhea with normal sexual development .
5. Uterine causes
Congenital : aplasia or hypoplasia .
Syndromes : see table in next page
a-Testicular feminization syndrome :
b-Mullerian agenesis :

 
Before Puberty 
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Investigation :
History
1-Personal history :
-Age : before puberty & after menopause → physiological .
-Marital status : suspect pregnancy .
-Occupation : overwork or stress .
2-Menstrual history :
-Determine 1ry or 2ry
-Determine duration of amenorrhea .
3-Obstetric history :
-If follows severe post partum hemorrhage : Sheehan's syndrome .
-If after puerperal sepsis : Asherman's syndrome .
4-Past history :
-Past history of chronic disease : e.g, DM , TB .
-Past history of operation : heavy curettage , hysterectomy .
-Past history of irradiation .
-Past history of hormone therapy : COCs , androgens .
5-Family history : of DM & TB .
6-Present history :
-1ry or 2ry . If 2ry : onset & duration .
-If related to delivery : lactation or Sheehan's syndrome .
-If related to stress : anorexia nervosa .
-If related to operation : Asherman's syndrome .
-If related to drugs : post pill or galactorrhea .
Examination
1-General examination :
-2ry sex characters +Tanner staging
-Height : short in Turner .
-Weight : underweight → anorexia . overweight → Cushing's , PCOSsuspect pregnancy .
-Anemia : TB .
-Goiter : thyroid dysfunction .
-Moon face & buffalo hump : Cushing .
-Webbed neck & cubitus vulgus : Turner's.
-Chest examination : TB .
-Breast examination : size (sign of endogenous estrogen) galactorrhea ,Signs of recent preg.
-Urine examination : for sugar .
2-Abdominal examination :
-Pubic hair : for androgenic pattern .
-Pelviabdominal swelling : → pregnancy → ovarian tumor
→ hematometra → full bladder .
-Inguinal canal : palpated for testes in testicular feminization syndrome .
3-Local examination:
-Inspection : → vulval development → imperforate hymen → clitoris size
-PV : → vaginal septum
→ Cx for signs of early pregnancy
→ Uterus & ovary for their size
-PR in virgins .
-Speculum exam. : for signs of early pregnancy in cervix .
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Special Investigations
** Investigations for uterine factor :
-Radiological : US , MRI pelvis , HSG
-Laparascope & hystroscope .
-Karyotyping
-Hormonal assay : LH , FSH , testosterone levels.
-Endometrial sampling .
-Uterine sound
-Progesterone challenge test + estrogen & progesterone withdrawal test .
** Investigations for ovarian factor :
-Radiological : US .
-Laparascope.
-Karyotyping .
-Ovarian biobsy .
-Hormonal assay : estrogen , progesterone , LH , FSH , , T3,T4, TSH ,androgens
-Progesterone challenge test + estrogen & progesterone withdrawal test .
** Investigations for Central factors :
-Radiological : CT & MRI brain , x-ray skull .
-Hormonal assay.
-GnRH test .
1ry amenorrhea
Search for : 2ry sex characters → breast
2ry sex organs → uterus
a- If both present : deal as 2ry amenorrhea except pregnancy test
b- Absent uterus + breast : testicular feminization or Mullerian agenesis
c- Under developed breast + uterus : Turner syndrome.
d- Both absent : abnormal androgen synthesis e.g, 5-α reductase deficiency . 
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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23. Secondary amenorrhea: causes, investigation (history, exam, special investigations)
(account).
Causes :
1. Cryptomenorrhea (Acquired Causes)
→ Gynatresia (post traumatic or post inflammatory )
→ Cervical conization or cauterization
→ Obstruction by a mass
→ Suturing ant. & post. uterine walls during CS
2. Hypothalamic causes
1) Traumatic : fracture base of the skull.
2) Inflammatory : meningitis , encephalitis .
3) Neoplastic : intracranial tumor causing destruction of the hypothalamus .
4) Post irradiation .
5) Psychogenic : (TTT : HRT)
a-Stress induced amenorrhea :
stress → ↑ catecholamines & endorphins & encepohalins → ↓ GnRH .
b-Anorexia nervosa : (wt. loss induced amenorrhea)
C/P → amenorrhea , bradycardia, constipation , dry skin, hypothermia
Bulemia nervosa → psychological disorder characterized by overeating , then self-
induced vomiting for fear of obesity
Inv. : → ↓ FSH , LH , T3 → ↑ cortisol
c-Exercise induced amenorrhea:
through critical level of body fat + hypothalamic suppression .
d-Pseudocyesis :
when there is strong desire or fear of pregnancy → 2ry amenorrhea .
6) Drug induced:
a-Drugs that ↑ prolactin :
b-Post pill amenorrhea : >6 M after stopping COCs or 12 months after DMPA.
3. Pituitary causes
1) Traumatic : fracture base of the skull.
2) Inflammatory : meningitis , encephalitis .
3) Neoplastic : Pituitary tumors
a-craniophryngioma : → arises from remnants of Rathke's pouch
→ compression on pituitary stalk & may lead to blurring of vision
→ TTT : surgery
b-Adenoma : → may be microadenoma or macroadenoma .
→ Most common are:Non functioning adenoma : usually surveillance
is sufficient prolactinoma→ amenorrhea & galactorrhea
(Frobes-Albright syndrome) .
→ TTT : dopamine agonist therapy
Surgery
Radiotherapy
4) Post irradiation .

After Puberty 
After Puberty 
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5) Syndromes :
a-Sheehan's syndrome :
Cause → Severe post partum hemorrhage → pituitary necrosis → panhypopituiterism .
C/P → ↓ gonadotropins → amenorrhea & infertility .
→ ↓ prolactin → failure to lactate (1
st
sign) .
→ ↓ ACTH → Addison's disease .
→ ↓ TSH → hypothyroidism.
→ ↓ MSH → pale waxy skin .
TTT → hormone replacement therapy
b-Simmond diosease :
-As Sheehan's but any other cause than post partum hemorrhaghe.
e-Chiarri-Fromel syndrome : (after delivery only)
-2ry amenorrhea & galactorrhea + 2ry infirtlity + 2ry genital atrophy
c-Empty Sella syndrome :
Cause : herniation of the subarachnoid space containing CSF into pituitary fossa .
C/P : amenorrhea , hyperprolactinemia & benign intracranial hypertension

4. Ovarian causes
1) Traumatic : Bilateral oophorectomy.
2) Inflammatory : mumps , TB .
3) Neoplastic : androgen secreting ovarian tumor .
4) Post irradiation .
5) Premature ovarian failure :
→ ovarian failure before 40 Y
→ Causes : genetic e.g, 45X0 Autoimmune disease
Infection & post irradiation or post chemotherapy
6) PCOS
5. Uterine causes
Traumatic : hysterectomy , Asherman's syndrome .
Asherman's syndrome
(intra uterine adhesions) (intra uterine syneachae)
Causes : traumatic : post D & C , post myomectomy , post CS.
inflamatory : Post partum , post abortive , TB .
C/P : partial → hypomenorrthea → recurrent abortion
total → amenorrhea → infertility
Inflammatory : TB & bilharziasis .
 
6. Other causes
1-Hypothyroidism
2-Hyperthyroidism
3-Addidson's disease
4-Cushing syndrome
5-Malnutrition , anemia , chronic debilitating diseases
6-Obesity .
 
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Investigation :
History
1-Personal history :
-Age : before puberty & after menopause → physiological .
-Marital status : suspect pregnancy .
-Occupation : overwork or stress .
2-Menstrual history :
-Determine 1ry or 2ry
-Determine duration of amenorrhea .
3-Obstetric history :
-If follows severe post partum hemorrhage : Sheehan's syndrome .
-If after puerperal sepsis : Asherman's syndrome .
4-Past history :
-Past history of chronic disease : e.g, DM , TB .
-Past history of operation : heavy curettage , hysterectomy .
-Past history of irradiation .
-Past history of hormone therapy : COCs , androgens .
5-Family history : of DM & TB .
6-Present history :
-1ry or 2ry . If 2ry : onset & duration .
-If related to delivery : lactation or Sheehan's syndrome .
-If related to stress : anorexia nervosa .
-If related to operation : Asherman's syndrome .
-If related to drugs : post pill or galactorrhea .
Examination
1-General examination :
-2ry sex characters +Tanner staging
-Height : short in Turner .
-Weight : underweight → anorexia . overweight → Cushing's , PCOSsuspect pregnancy .
-Anemia : TB .
-Goiter : thyroid dysfunction .
-Moon face & buffalo hump : Cushing .
-Webbed neck & cubitus vulgus : Turner's.
-Chest examination : TB .
-Breast examination : size (sign of endogenous estrogen) galactorrhea ,Signs of recent preg.
-Urine examination : for sugar .
2-Abdominal examination :
-Pubic hair : for androgenic pattern .
-Pelviabdominal swelling : → pregnancy → ovarian tumor
→ hematometra → full bladder .
-Inguinal canal : palpated for testes in testicular feminization syndrome .
3-Local examination:
-Inspection : → vulval development → imperforate hymen → clitoris size
-PV : → vaginal septum
→ Cx for signs of early pregnancy
→ Uterus & ovary for their size
-PR in virgins .
-Speculum exam. : for signs of early pregnancy in cervix .
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Special Investigations
** Investigations for uterine factor :
-Radiological : US , MRI pelvis , HSG
-Laparascope & hystroscope .
-Karyotyping
-Hormonal assay : LH , FSH , testosterone levels.
-Endometrial sampling .
-Uterine sound
-Progesterone challenge test + estrogen & progesterone withdrawal test .
** Investigations for ovarian factor :
-Radiological : US .
-Laparascope.
-Karyotyping .
-Ovarian biobsy .
-Hormonal assay : estrogen , progesterone , LH , FSH , , T3,T4, TSH ,androgens
-Progesterone challenge test + estrogen & progesterone withdrawal test .
** Investigations for Central factors :
-Radiological : CT & MRI brain , x-ray skull .
-Hormonal assay.
-GnRH test .

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Pregnancy test


+ve -ve


Pregnancy Prolactin & TSH levels


Abnormal levels Normal levels

Deal with it Progesterone challenge test


Bleeding No bleeding


Anovulation


Estrogen & prog. withdrawal test



No bleeding Bleeding

Uterine factor FSH level


High Low


Ovarian factor GnRH test


Bleeding No bleeding

Hypothalamic factor Pituitary factor
 
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24. Intra-uterine adhesions (Asherman's syndrome): causes, diagnosis and treatment.(MCQ).
Causes : traumatic : post D & C , post myomectomy , post CS.
inflamatory : Post partum , post abortive , TB .
Diagnosis :
C/P : partial → hypomenorrthea → recurrent abortion
total → amenorrhea → infertility

Inv. : → uterine sound.
→ HSG : multiple filling defects.
→ Hystroscope : visualization of adhesions .

TTT : of partial
Dilatation of the cervix & cutting the adhesions under vision using hystroscope.
+ Post operative → Foley's catheter for 1 W or IUD for 2 cycles
→ Estrogen for 3-4 W ending with a coarse of gestagens .
→ Antibiotics for 10 days

25. Prolactin hormone: structure. Site of secretion and biologic functions. .(MCQ).
Structure : 191 AA (water soluble polypeptide)
Site of secretion : acidophil of anterior pituitary .
Biologic functions : 1-lactation
2-Essential for corpus luteum function
3-Inhibit ovulation after fertilization

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26. Hyperprolactinemia: causes ,clinical picture , special investigations and treatment.
(account).
Causes
A-Physiological : → Pregnancy. → Lactation.
→ Sexual intercourse and orgasm. → Stress.
B- Pathological: the commonest three causes are :
1. Pitiutary tumors : microadenoma (<1O mm) or macro-adenomas (>1O mm).
2. Primary hypothyroidism: ↑TSH → ↓ dopamine → ↑ prolactin production.
3. Iatrogenic :drugs that cause dopamine depletion as : Antihypertensive (Reserpine)
Psychotropic drugs. , Oral contraceptives,H2 blockers, metoclopramid & Opioids.
4. Other causes : → chronic renal failure especially after hemodialysis.
→ Chest wall wound or scar.
→ Herpes Zoster infection.
Clinical picture
1. Galactorrhea : inappropriate milk secretion from the breast
not related to pregnancy, lactation & puerperium.
2. Oligomenorrhea and amenorrhea (anovulation}
3. Infertility.
Special investigations
1-Serum prolactin >20ngm/ml (normal level).
2-If PRL level >50ngm/ml → CT scan and MRI of the brain .
3-TSH level to exclude hypothyroidism.
4-Review of patient current medications.
Treatment
A. Medical Treatment :
1. Dopamine Agonists: (Bromocriptine mesylate)
→ It is an ergot derivative.
→ (++) dopamine receptors in the brain & pituitary gland → it (--) PRL secretion.
→ Dose: 1.25mg /day at the evening for 1 week then increased in
1.25 mg increments / 2-3 weeks (to decrease the side effects).
→Side effects : GIT disturbances: nausea & vomiting in 60% of patients , Headache,
Orthostatic hypotension & nasal congestion.
2. Cabergoline: dopamine agonist with longer half life, so it is given in semiweek doses
3. Ovulation Induction: → By dopamine agonists
→ GnRh analogues in pulsatile manner every 60 to 120 minutes.

B. Surgery & radiotherapy :
→ visual defects and CNS disturbances
→ failed medical TTT

 
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27. Polymenorrhea : definition – causes- treatment , Metrorrhagia : definition –
causes.(account). Menorrhagia: definition – causes- (local general, dysfunctional),
Dysfunctional menorahgia: mechanisms, symptoms , signs, DD, investigations, treatment
(general, medical , hormonal, surgical ttt) .(account).
Polymenorrhea
Definition
Frequent menstruation recurring every < 21 d (3W)
Causes
Organic:
• Ovarian congestion
• Pathological pelvic congestion
Hormonal:
Dysfunctional polymenorrhea : due to either
-Short follicular phase .
-Short luteal phase .
Treatment
- Regulation of the cycle by cyclic estrogen & progesterone
Metrorrhagia
Definition
Irregular uterine bleeding not related to menstruation .
Causes
Organic:
A-General causes : 6 H
1-Hypertyension . 2-Heart failure .
3-Hyperthyroidism . 4-Hemorrhagic Bl. diseases : e.g, hemophilia
5-Hemorrhagic drugs : e.g, anticoagulants. 6-Hemorrhagic fevers .
B-Local causes :
1-Obstetric causes : → Bleeding in early pregnancy (abortion , ectopic, vesicular mole)
→ Antepartum hemorrhage .
→ Post partum hemorrhage .
2-Gynecologic causes :
a-Congenital causes :
b-Inflammatory causes :
→ Vulvovaginitis of children → senile vaginitis → Chronic cervicitis → Endometritis
→ cervical erosion → Chronic PID → Senile endometritis
c-Traumatic causes :
→ Defloration injury → Instrumental use
→ Laceration in genital tract → Foreign body e.g, IUD
d-Neoplastic causes :
→ Cancer vulva → Cancer cervix
→ Cancer vagina → Functioning ovarian tumor
→ Endometrial carcinoma → uterine sarcoma → choriocarcinoma
→ fibroids → endometriosis → polyps
 
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Hormonal: (Expect dysfunctional menorahgia)
1-Dysfunctional uterine bleeding (DUB) .
2-Iatrogenic : HRT .
3-COCs : irregular or accidental intake .
4-Birth crisis .
5-Precocious puberty.

Menorrhagia
Definition
↑ Amount ( > 80ml) and ↑ duration ( > 7days) of menstrual flow .
Causes
Organic:
A-General causes : 6 H
1-Hypertyension . 2-Heart failure .
3-Hyperthyroidism . 4-Hemorrhagic Bl. diseases : e.g, hemophilia
5-Hemorrhagic drugs : e.g, anticoagulants. 6-Hemorrhagic fevers .
B-Local causes : (causes of pelvic congestion)
-Simple : constipation & coitus interuptus
-Pathological: causes of pelvic congestion
1. Cong. : imperforate hymen
2. Inf. : PID , chronic cervicitis
3. Traumatic : IUD
4. Neoplastic : all neoplasms
5. Others : prolapse , endometriosis .
Dysfunctional:
- Irregular ripening of endometrium CL insufficiency (LPD)
- Irregular shedding of endometrium Persistent CL functions


Dysfunctional menorahgia
Irregular ripening of endometrium Irregular shedding of endometrium
Cause &
Mechanism
s
-CL insufficiency (LPD)
-LPD → ↓ progesterone release from
CL → areas of endometrium not
controlled by progesterone → early
shedding of these parts before
menstruation
-Persistent CL functions.
-Persistent CL functions → persistent
release of progesterone → areas of
endometrium still controlled by
progesterone → late shedding of
these parts after menstruation .
Symptoms
-Irregular vaginal bleeding followed
by menstruation.

-Menstruation followed by irregular
vaginal bleeding.
Signs
Possibilities of
endometrium in
D & C

-PMEB : mixed pattern (both
secretory & proliferative but
secretory is the dominant .


-Endometrial biopsy during bleeding:
mixed pattern (both secretory &
proliferative but proliferative is
the dominant .

TTT Briefly

-Giving progesterone during 2
nd
half
of the cycle .

-Hormonal regulation of the cycle .
 
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DD
- Firstly It is diagnosed by exclusion:
1-Cyclic :(regular) a-Ovular: dysfunctional polymenorrhea
dysfunctional menorrhagia → irregular ripening of endometrium
→ irregular shedding of endometrium.
b-Anovular: pseudomenstruation with COCs .

2-Acyclic : (irregular) (anovular) a-Threshold (withdrawal) bleeding .
b-Metropathia heamorrhagica.
Investigations
As Special Investigations  in DUB مدﺎﻘﻟا لاﺆﺴﻟا  
Treatment
I-General TTT :
II-Medical (Non hormonal) TTT :
III-Hormonal TTT :
IV.Surgical treatment :
 
As DUB مدﺎﻘﻟا لاﺆﺴﻟا
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28. Dysfunctional uterine bleeding : definition, age, classification, how to diagnose
dysfunctional uterine bleeding (history, exam: special investigations) , treatment (general,
medical , hormonal, surgical ttt). Metropathia hemorrahgica : age – pathology of uterus &
ovaries . , treatment (general, medical , hormonal, surgical ttt).(account).
Dysfunctional uterine bleeding
Definition
-Abnormal uterine bleeding in absence of gross pelvic lesion i.e, due to functional disturbance
in normal mechanism of menstruation (hypothalamo-pituitary ovarian axis) .
-It is diagnosed by exclusion .

Age (Incidence)
-In general 10% of all gynecologic patients .
-The most common cause of abnormal uterine bleeding .
-Common in the extremes of reproductive age i.e, perimenarcheal & perimenopausal .

Classifications :
A-Etiological classification :
1-1ry DUB : Due to disturbed hypothalamo-pituitary –ovarian axis .
2-2ry DUB : Due to general causes or hormonal contraception or IUD .

B-Clinical classification :
1-Cyclic :(regular)a-Ovular: dysfunctional polymenorrhea
dysfunctional menorrhagia → irregular ripening of endometrium
→ irregular shedding of endometrium.
b-Anovular: pseudomenstruation with COCs .

2-Acyclic : (irregular) (anovular) a-Threshold (withdrawal) bleeding .
b-Metropathia heamorrhagica.
C-Hormonal classification :
1-Estrogen withdrawal bleeding :
-Due to : ↓ estrogen level .
-Occurs in : → cessation of exogenous estrogen .
→ ovulation spotting
2-Estrogen breakthrough bleeding :
-Due to : chronic hyperestronemia → (++) proliferation of endometrium → outgrows
structural stromal support → endometrial breakdown.
-Occurs in : → metropathia hemorrhagica .
3-Progesterone withdrawal bleeding :
-Due to : ↓ progesterone level in estrogen primed endometrium .
-Occurs in : → cessation of exogenous progesterone e.g, contraceptive pills .
4-Progesterone breakthrough bleeding :
-Due to : prolonged progesterone administration .
-Occurs in : → long acting injectables .
 
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How to diagnose
History
-Age : DUB is a disease of extremes of reproductive period .
-If preceded by period of amenorrhea → suspect pregnancy .
-If preceded by trauma.
-Hx. of hormonal therapy .
-Chriteria of bleeding : amount , color , pattern .
-Associated pain , discharge or loss of weight .
-Bleeding from other orifices .

Examination
1-General examination :
-Evaluate effect of bleeding on vital data .
-Search for general cause e.g, goiter , heart failure , …. etc .
2-Abdominal examination :
-Ovarian tumor .
3-Local examination:
-Complete & accurate local examination to search for a cause .

special investigations
A-Methods to assess the endometrium :
1-TAS , TVS & sonohystrography .
2-Endometrial sampling :
→ by aspiration using small catheter to role out endometrial carcinoma.
→ Indications : → women at risk for endometrial hyperplasia
→ women at risk for endometrial carcinoma
→ women >40 Y
→ women <40 Y with chronic unopposed estrogen break through bleeding
3-Fractional D & C :
Indications : should be restricted to
→ DUB not responding to TTT with hormonal therapy .
→ Endometrial sampling can't be done as office procedure due to cervical stenosis .
Steps : → general anesthesia
→ evacuate bladder
→ EUA
→ endocervical curettage (1
st
sample)
→ uterine sound
→ low corporeal curettage (2
nd
sample)
→ high corporeal curettage (3
rd
sample)
Value : → diagnostic
→ therapeutic : to stop bleeding .
Possibilities in DUB : as before
Possibilities in perimenopausal bleeding : as DUB + → endometritis
→ malignant endometrium
4-Hystroscope :
Indications : when submucous fibroid or intracavitary polypi are suspected
(can be removed in the same sitting)
(hystroscope must be followed by D & C to role out associated endometrial pathology)

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B-Others :
1-Clinical : EUA (examination under anesthesia )
2-Labaratory : → blood : CBC , coagulation profile .
→ Hormonal assay including thyroid hormones & prolactin .
3-Radiologic : → HSG
→ CT & MRI
4-Endoscopy : → laparascope
→ culdoscope.
5-Biopsy : → vaginal smear
→ PAP smear
6-Others : → tests for ovulation
→ Schiller's I test .
Treatment
I-General TTT :
1-Rest , good diet , minerals & iron supplementation .
2-Hemostatics : e.g dycinone , daflon .
3-Blood transfusion if needed .

II-Medical (Non hormonal) TTT :
1-Antifibrinolytics → ↓ fibrinolytic activity → ↓ blood loss .
→ e.g, tranexemic acid , EACA(epsilon amino caproic acid) .
2-Anti prostaglandins → ↓ synthesis of PGs + alter TxA2/PGI2 ratio → ↓ blood loss .
→ e.g, mefenamic acid , ibuprofen .
3-Ethamesylate (dycinone) : ↓ capillary fragility .

III-Hormonal TTT :
1-Gestagens :
Indications : TTT of choice , because most cases of DUB are unovulatory .
Mech. Of action : → ↓ estrogen receptors on the endometrium .
→ antimitotic effect.
→ antigrowth effect.
→ conversion of E2 into E1 easily displaced from cell.
→ conversion of hyperplastic endometrium into secretory
endometrium followed by shedding (medical curettage)
Types : → 19 norsteroids : norethisterone .
→ 17 hydroxy progesterone : MPA.
Dose: → To arrest bleeding :
10-30 mg/day for 10 days
→ in metropathia hemorrhagica :
1 X 2 X 3 w , then rest for 1 w then continue for 3 cycles .
→ in CL insufficiency :
1 X 2 X 10 d from day 15 till day 25, then rest for 1 w then continue for 3 cycles
Side effects : wt. gain , vaginal dryness , mastodenia , depression .

N.B : LNG(levo nor gestril) IUD
→ adv. : Alocal effect decreasing systemic side effects
→ disadvantages : may cause irregular bleeding for many weeks after insertion .

2-COCs :
Indications : acute bleeding in young women only .
Mech. Of action : regulation of the cycle by control of endometrium .
Dose : use low dose pills : 2-3 times/day for 7 days , then allow withdrawal bleeding ,
after that start cyclic therapy one tablet/day for 3 months .
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3-Estrogen :
Indications : → severe bleeding
→ bleeding due to gestagen therapy .
Mech. Of action : act on the endometrium → rapid proliferation & growth → cover
the denuded & raw areas in the endometrium → stop bleeding .
Dose : EE2 or premarin for 7-10 days .

4-GnRH agonists :
-Used after control of acute bleeding to induce amenorrhea in chronically ill patients ,
or as a preoperative preparation to ↓ endometrial thickness .

5-Danazole : (testosterone derivative)
-Used as a preoperative preparation to ↓ endometrial thickness .
-Disadvantages : expensive & virilizing side effects .

IV.Surgical treatment :
1.D & C with or without hysteroscopy : (Not the procedure of first choice)
-Indications : → The bleeding is refractory to medical treatment.
→ The women are not candidate for hormonal therapy.
-Value : → diagnostic : for endometrial pathological type.
→ therapeutic : to stop bleeding.

2.Hysterectomy:
-Indications:→ When the patient completed her family.
→ Patient doesn't tolerate hormonal or medical therapy.
→ Patient with atypical hyperplasia.

3.Alternatives to hysterectomy :
A.Hysteroscopic endometrial ablation:
-Indications : → Patient with medical contraindications to surgery.
→ The patient refuses surgery .
-Methods of ablations : → Laser.
→ Electrocautary.
→ Thermal balloon ablation.
-Best results are achieved when:
a. Patient is older than 35 years. b.DUB.
c. Uterus <10 weeks (cavity <10cm). d. During early proliferative phase.
e. Pretreatment e' gestagens or danazole for 6 w. f. No endometriosis or adenomyosis.
-Results: 50% : amenorrhea. 20-40% : ↓ bleeding. 20% with no improvement.

B. Bilateral uterine arteries embolization.

C.Laparoscopic myolysis.

Metropathia hemorrhagica : (Schroeder's syndrome)
Age
Pathology :
Uterus : → N/E : symmetrically enlarged , thick endometrium & soft .
→ M/E : cystic endometrial hyperplasia (swiss cheese appearance)
Ovaries : → N/E : bilateral polycystic ovaries .
→ M/E : cysts lined by granulosa cells .
TTT : as DUB ﺔﻘﺑﺎﺴﻟا ﺔﺑﺎﺟﻹا

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29. Postmenopausal bleeding : definition – causes ( general ,local, hormonal) diagnosis
(history, exam: special investigations) .(account).
Definition
-Any bleeding from female genital tract after menopause till death
Causes
General causes : 6 H
1-Hypertyension . 2-Heart failure .
3-Hyperthyroidism . 4-Hemorrhagic Bl. diseases : e.g, hemophilia
5-Hemorrhagic drugs : e.g, anticoagulants. 6-Hemorrhagic fevers .
Local causes :
a-Inflammatory causes :
→ Senile vaginitis .
→ atrophic endometritis (most common cause) .
c-Traumatic causes :
→ post coital bleeding
→ FB , direct trauma .
d-Neoplastic causes :
→ all except sarcoma botryoides & germ cell tumors .
→ Especially endometrial carcinoma (most serious) .
Any postmenopausal bleeding is considered malignant till proved otherwise ,
not because it is the most common but because it is the most serious .
Hormonal : 1-HRT .

 
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Diagnosis : ﻲﺼﺨﺷ دﺎﻬﺘﺟا ??
History
-Age : after menopause till death.
-If preceded by trauma.
-Hx. of hormonal therapy .
-Chriteria of bleeding : amount , color , pattern .
-Associated pain , discharge or loss of weight .
-Bleeding from other orifices .

Examination
1-General examination :
-Evaluate effect of bleeding on vital data .
-Search for general cause e.g, goiter , heart failure , …. etc .
2-Abdominal examination :
-Ovarian tumor .
3-Local examination:
-Complete & accurate local examination to search for a cause .

special investigations
A-Methods to assess the endometrium :
1-TAS , TVS & sonohystrography .
2-Endometrial sampling :
→ by aspiration using small catheter to role out endometrial carcinoma.
→ Indications : → women at risk for endometrial hyperplasia
→ women at risk for endometrial carcinoma
→ women >40 Y
3-Hystroscope :
Indications : when submucous fibroid or intracavitary polypi are suspected
(can be removed in the same sitting)
(hystroscope must be followed by D & C to role out associated endometrial pathology)
B-Others :
1-Clinical : EUA (examination under anesthesia )
2-Labaratory : → blood : CBC , coagulation profile .
→ Hormonal assay including thyroid hormones & prolactin .
3-Radiologic : → HSG
→ CT & MRI
4-Endoscopy : → laparascope
→ culdoscope.
5-Biopsy : → vaginal smear
→ PAP smear
6-Others : → tests for ovulation
→ Schiller's I test .
 
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30. Causes of bleeding per vagina according to age . (account).
1-Organic lesion :
A-General causes : 6 H
1-Hypertyension . 2-Heart failure .
3-Hyperthyroidism . 4-Hemorrhagic Bl. diseases : e.g, hemophilia
5-Hemorrhagic drugs : e.g, anticoagulants. 6-Hemorrhagic fevers .
B-Local causes :
1-Obstetric causes : → Bleeding in early pregnancy (abortion , ectopic, vesicular mole)
→ Antepartum hemorrhage .
→ Post partum hemorrhage .

2-Gynecologic causes :
a-Congenital causes :
b-Inflammatory causes :
→ Vulvovaginitis of children → senile vaginitis
→ Chronic cervicitis → cervical erosion
→ Endometritis → Senile endometritis
→ Chronic PID
c-Traumatic causes :
→ Defloration injury
→ Laceration in genital tract
→ Instrumental use
→ Foreign body e.g, IUD
d-Neoplastic causes :
→ Cancer vulva
→ Cancer vagina
→ Cancer cervix
→ Endometrial carcinoma → uterine sarcoma → choriocarcinoma
→ Functioning ovarian tumor
→ fibroids → endometriosis → polyps

2-Hormonal :
1-Dysfunctional uterine bleeding (DUB) .
2-Iatrogenic : HRT .
3-COCs : irregular or accidental intake .
4-Birth crisis .
5-Precocious puberty.

31. RVF : MCQ
  
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32. Pelvic organ prolapse : factors supporting normal position of uterus, high risk factors
(predisposing and precipitating factors) of Pelvic organ prolpase. Types of vaginal prolapse
& degrees of uterine prolapse : symptoms , signs , prophylactic treatment ,surgical
treatment (preoperative preparations , operations in childbearing ,operations in
menopausal patients .Classic repair : indication, components .Fothergilles operation :
indication, steps ,complications. Repair for hernia of Douglas pouch .(account).
Factors supporting normal position of uterus
1ry : cervical ligaments (cardinal , uterosacral , pubocervical) .
2ry : a-AVF position of the uterus, w' is maintained by :
→Rapid growth of the posterior than the anterior uterine wall.
→Wt. of intestine & ↑ intra-abd. press. : push the corpus downward.
→Round ligaments : pull the fundus forward.
→uterosacral ligament : pull the cervix backward.
b-Levator ani (minor role)
c-Surrounding viscera
d-Corporeal ligaments

High risk factors
I-Predisposing factors :
A-Congenital causes:
-Congenital weakness of the supporting structures → appearance of prolapse at
younger age, the so-called "virginal" or "nulliparous" prolapse.
-The weakness in the fascial support may be generalized thus, this usually
associated with : Hernia and piles or visceroptosis ,
Spina bifida (occulta or manifesta) .
Congenital RVF uterus & short vagina.
B-Weakness of the support due to pregnancy:
-Due to softening of fascial support by progesterone & cortisol + uterine weight .
C-Weakness of Support due to Child-Birth Trauma : (Badly Managed Labor)
1. Straining in the first stage of labor.
2. Prolonged second stage of labor.
3. Application of forceps or vacuum before full cervical dilatation.
4. Breech extraction before full cervical dilatation.
5. Delivery of oversized baby : → hidden perineal tear
→ denervation injury of the muscle.
6. Injury of the perineal body : → the urogenital hiatus will become wide with a tendency of the uteru
vagina to prolapse through it.
7. Downward pressure on the uterus during fundal pressure .
8. Downward traction on the uterus during delivery of placenta (Crede method)
9. Repeated unspaced pregnancies.
10. Absence of post-natal pelvic floor muscle exercises.
D-Weakness due to postmenopausal atrophy:
-After the menopause the pelvic ligaments lose their tone due to hypoestrogenemia .
E-Surgical trauma:
-Traction on the cervix in gynecologic operations & subtotal hysterectomy where
the cervix acts as an apex of intussusception and encourages the vault to invert.
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II-Precipitating factors:
1-Increased intra-abdominal pressure e.g, chronic cough, chronic constipation, straining,
heavy lifting, abdominal tumors & ascites.
2-Increased weight of the uterus by a small fibroid and subinvoluted uterus.
[
Types of vaginal prolapse
1-Urethrocele:
-Prolapse of the lower 1/3 of the anterior vaginal wall with the urethra behind it.
2-Cystocele:
-Prolapse of the upper 2/3 of the anterior vaginal wall with the bladder behind it.
3-Rectocele:
-Prolapse of the lower part of the posterior vaginal wall with the rectum behind it.
4-Hernia of the pouch of Douglas:
-Prolapse of the upper part of the posterior vaginal wall.
-If contains loops of intestine → enterocele .
Degrees of uterine prolapse
1-First degree:
-External os below the level of ischial spines , but don't appear outside the vagina.
2-Second degree:
-External os outside the vagina , but body of uterus (or part of it) is inside vagina .
3-Third degree : (complete prolapse) (procedentia)
-The whole uterus is outside the vagina .
Symptoms
A-Before manifest prolapse:
-Sensation of vaginal fullness or sensation of weakness in the perineum.
B-After prolapse:
1-A mass protruding from vulva : that increase or appear by straining or
standing & decrease or disappear when the patient lies down.
2-Backache due to stretching of the uterosacral ligaments ( with uterine descent).
3-Symptoms of pelvic congestion:
-Congestive dysmenorrhea, dysparuenia , menorrhagia and leucorrhea.
4-Urinary symptoms: with cystocele
1. Frequency of micturition.
2. Stress incontinence.
3. Urge incontinence.
4. Pain in the loin due to associated pyelonephritis.
5. Dysuria.
6. Difficulty in urination unless the anterior vaginal wall is pushed above the
level of the internal urethral meatus.
7. Retention of urine.
5-Rectal symptoms : with rectocele
1-Dyschazia.
2-Difficulty in defecation unless the posterior vaginal wall is pushed above.
3-Sense of incomplete emptying.

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6-Symptoms of complications:
1-Offensive vaginal discharge caused by infection and ulceration.
2-Loin pain and manifestations of renal failure.
3-Infertility : vagina → dysparuenia
Cervix → chronic cervicitis
Uterus → RVF
→ congested endometrium not suitable for implantation .
Tubes → kinked
Ovaries → congestive anovulation .
Signs
1-General examination:
-Look for anemia, manifestations of chronic bronchitis or uremia.
-Back examination for spina bifida .
2-Abdominal examination:
-Palpate the kidneys.
-Examine for any abdominal masses or ascites.
-Look for associated umbilical or inguinal hernia.
3-Local examination:
A-Inspection :
-Ask the patient to strain down to show part descend :
■ If the cervix comes down at the introitus → 2
nd
or 3
rd
degree uterine descent.
■ If anterior vaginal wall comes down → cystocele.
■ If posterior vaginal wall comes down → a rectocele or occasionally enterocele
-Ask patient to cough with full bladder: Escape of urine → stress incontinence
-Examine for : evidence of old perineal lacerations or trophic ulcers .
-Deficient perineum → lower part of post. vaginal wall is seen without separation

B-Palpation:
-Two fingers in the posterior fornix . Ask the patient to strain down or to
cough : presence of impulse on cough or gurgling sensation → enterocele.
-Assess Levator ani tone by 2 fingers in vagina and asking the patient to hold up.
-Assess the perineal body by 2 fingers in the vagina and the thumb on the perineum.
-Differentiate ( ) 2
nd
& 3
rd
degree uterine descent→finger grip test : put the thumb
on anterior vaginal wall & the index on posterior vaginal wall at the introitus :
If the fundus is felt below the 2 fingers (fingers can meet) → 3
rd
degree
If you failed to get above the fundus → 2
nd
degree prolapse.
C-Bimanual examination:
-The size and site of the uterus .
-The state of the adnexae .
D-Speculum examination:
-The cervix should be exposed by a speculum for : → infection
→ trophic ulcers.
-Speculum withdrawal : if mass in upper 1/3 → enterocele .
if mass in middle 1/3 → rectocele .
E-Uterine sound :
-To measure the length of cervix → for detection of supravaginal elongation .
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F-Rectal examination :
-To differentiate between rectocele and enterocele → finger enters mass
only in rectocele .
G-Special tests :
1-For stress incontinence (SI) :
-Stress test : Ask patient to cough with full bladder: Escape of urine → SI
-Yousef test : if –ve stress test → reduce prolapse (manually, by a volsellum
or by a pessary) & ask the patient to cough : Escape of urine → hidden SI .
-Bonney's test : elevate the vaginal wall to retropubic position by 2 fingers in
in the vagina & ask patient to cough :
If SI disappear → patient will benefit from surgical elevation of the bladder.
If SI persist → a case of intrinsic sphincter deficiency .

2-For differentiation ( ) rectocele & enterocele :
-PR : finger enter the mass in rectocele only .
-Malpas test (combined PR & PV) : Put the middle finger in the rectum & the
index finger in the vagina and ask the patient to cough, the mass will be felt
between the examining fingers in enterocele only .
-Speculum withdrawal : as before .

3-For differentiation ( ) 2
nd
& 3
rd
degree uterine descent :
-Finger grip test (getting above test) : as before .

4-For supravaginal elongation :
-Uterine sound . -Higar's dilators . -Folley's catheter .

Prophylactic treatment (Prevention ) :
1-Correction of malnutrition & anemia .
2-Proper TTT of any factor increasing intra-abdominal press. e.g, chronic constipation .
3-During labor : etiology ﺲﻜﻋ .
4-During puerperium : → care against infection
→ frequent evacuation of bladder
→ pelvic floor muscle exercises .
5-During hysterectomy : suturing ligaments to the vaginal vault .
6-During postmenopausal period : estrogen .

 
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Surgical treatment :
Preoperative preparations :
1-Timing of surgery:
-After menstruation:
a. The blood flow to pelvic organs is minimal to avoid excessive bleeding
due to surgery.
b. To avoid the possibility of disturbing early pregnancy.
c. To give time for wound healing before the next menstruation.
3-6 months after last delivery to allow the maximum resolution of tissues.
2-Anemia : should be treated to maximize tissue healing.
3-Chronic constipation : should be treated .
4-chest infection : should be treated .
5-Vaginal, cervical and urinary tract infections : should be treated.
6-Trophic ulcers must be treated by:
-Reposition of the prolapsed organs → restore circulation & eliminate hypoxia.
-Daily vaginal packing .
-Conjugated estrogen (premarin) local ointments → improves healing power .
-Ulcers that are slow to heal : painted with silver nitrate.
7-Prophylactic antibiotics should cover both gram -ve and gram +ve organisms.
8-Thromboembolic prophylaxis : In obese patients to avoid DVT .
9-Minimize blood loss : local infiltration of 0.5 xylocaine & 1/200.000 adrenaline.


Operations in childbearing
- Rectocele : posterior colpoperineorraphy .
- Cystocele : anterior colporrhaphy ?? or classical repair .
- Cysto-rectocele : classical repair .
- Cysto-rectocele + 1
st
degree uterine descent :
Classica repair + shortening of Mackenrodt's ligaments .
- Cysto-rectocele + 2
nd
or 3
rd
degree uterine descent :
Patient >40Y or completed her family → vaginal hysterectomy & repair of pelvic floor .
Patient <40Y & need fertility → Fothergill's operation .
- Enterocele : vaginal or abdominal repair .

Operations in menopausal patients
- Rectocele : posterior colpoperineorraphy .
- Cystocele : anterior colporrhaphy ?? or classical repair .
- Cysto-rectocele : classical repair .
- Cysto-rectocele + uterine descent :
Sexually active : vaginal hysterectomy + repair of pelvic floor .
Sexually inactive : Le fort's operation .

 
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Classical repair :
**Indications : → Cystocele alone.
→ Cystocele and rectocele.
→ Cystocele and rectocele with 1
st
degree uterine prolapse.
→ Cystocele & rectocele + 2
nd
degree uterine prolapse + no
supravaginal elongation of the cervix in women below 40 years.
** components : → Anterior colporrhaphy.
→ Shortening of Mackenrodt's ligaments.
→ Posterior colpoperineorrhaphy.
(Mackenrodt's ligaments are sutured together & in front of Cx. →
become short → correct retroversion & 1
st
degree uterine prolapse).
Fothergill's operation:(Manchester operation)
**Indications : Cystocele & rectocele + 2
nd
, 3
rd
degree uterine prolapse + supravaginal
elongation of the cervix in women below 40 years desiring fertility.
**Steps : → dilatation of the cervix ( up to Hegar 12)
(to facilitate covering the raw area after amputation of cx. by mucosa)
→ Anterior colporrhaphy.
→ amputation of the elongated cervix
→ Shortening of Mackenrodt's ligaments.
→ Posterior colpoperineorrhaphy.
**Long term complications :
→ Cervical stenosis : infertility , cervical dystochia , dysmenorrhea .
→ Cervical incompetence : Recurrent abortion & preterm labor .
→ Recurrent prolapse.
→ Enterocele formation.
→ Complications of any vaginal operation : dysparuenia& tender vaginal
scar , severe bleeding , infertility , injury to surrounding structures .

Repair for hernia of Douglas pouch (Enterocele)
a- Vaginal repair:
-The operation is similar to that of a rectocele, but the posterior vaginal wall
is dissected upwards till the posterior fornix.
-The hernial sac is identified and dissected freely. The top of the sac is
opened & transfixed by a purse string (Vicryl) suture.
-The two uterosacral ligaments are sutured together in the middle line and the
prerectal fascia is repaired.
-A posterior Colpoperineorrhaphy .
b- Abdominal repair : (Moschowitz operation)
-The Douglas pouch is obliterated by a series or purse string sutures.
-The needle bites include the uterosacral ligaments, the posterior
wall of the cervix & the anterior serous coat of the rectum.

33. Differential diagnosis of mass protruding from vulva .(MCQ).

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34. Common types of primary vaginitis: vulvo-vaginitis of children (etiology , mode of infection
,symptoms ,signs, special investigations & treatment) ,senile atrophic vaginitis (etiology,
symptoms ,signs, treatment). Contrast trichomonas vaginitis & vulvo- vaginal candidosis
regarding : causative organism , mode of infection & symptoms, signs , treatment
(table).Bacterial vaginosis :causative organism: mode of infection & symptoms, signs ,
complications, treatment.(account).
Common types of primary vaginitis :
1. Trichomonas vaginitis
2. Vulvo-vaginal candidosis
3. Bacterial vaginosis
4. Vulvo-vaginitis of children
5. Senile atrophic vaginitis

Vulvo-vaginitis of children (Prepubertal Vulvovaginitis) :
Etiology
I- Infectious causes:
1- Non specific (80%): Commonly with E.coli, streptococci, staph aureus and proteus.
2- Specific infections:
a- Candida. b- Trichomonas.
c- Neisseria (doesn't occur in postpubertal age). d- Gardnerella.
II- Non infectious causes:
1-Allergy. 2-Epithelial dystrophies. 3- Neoplasms.
III- Predisposing factors:
1- Poor hygiene. 2- Congenital lesions as congenital fistula or ectopic anus.
3- F.B. 4- Oxyuris infestation.
5- General ill health and decreased immunity.
Mode of infection
1- Usually through contact with contaminated material.
2- Fecal contamination of the vestibule.
3- Rarely sexual abuse.
Symptoms
Pain, itching, insomnia, vaginal discharge.
Signs
Vulvitis, itching marks, discharge, vaginitis (if the vagina is examined by
pediatric cystoscope, pediatric vaginoscope, nasal speculum or laryngoscope). PR is
also helpful.
Special investigations
Include U/S, X-Ray for detection of FB and investigations for detection of oxyuris infestation.
Treatment
1 - Treatment of the underlying factor as oxyuris infestation.
2- Local cleanliness by sterilization of clothes, washing of the vulva & perineum with
antiseptic solution (chlorhexidine, 0.01% =Savlon) after micturition or defecation
followed by drying.
3- Proper antibiotic.
4- Estrogen therapy lOug EE/12hrs for 2 Ws the lOug/day for another 2 Ws.
5- Measures to prevent other children infection.
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Senile atrophic vaginitis
Etiology
Loss of many of the protective barriers as:
1- Loss of vaginal acidity and Doderlein bacilli.
2- Atrophy of the vaginal and vulvar epithelium.
3- Opening of the vaginal introitus due to atrophy of labia majora.
4- Higher risk of forgetting vaginal FBs.
5- Higher risk of general ill health related to age.
Symptoms
As any vulvovaginitis with dyspareunia and contact bleeding in some cases.
Signs
Atrophy of the external genitalia and loss of the vaginal rugae. The vaginal skin may be somewhat
friable in areas +vaginitis or vulvovaginitis.
Treatment
1 - Exclusion of underlying genital malignancy.
2- Topical estrogen vaginal cream. Use of 0.3mg of conjugated estrogen cream intravaginally
each day for 1-2 weeks generally provides relief. Systemic estrogen replacement therapy should be
considered to prevent recurrence of this disorder.
3- Lactic acid douches (0.5-1%). Application of trophigil vagijial (E +Progesterone +Lactobacilli) is
also helpful.

Contrast trichomonas vaginitis & vulvo- vaginal candidosis


Vaginal candidiasis
(Moniliasis)
Trichomonas vaginitis
(Trichomoniasis)

Causative
organism
-Candida species : albicans (80%) ,
-Fungi.
-Trichomonus vaginalis
-Anaerobic flagellated protozoan.
Mode of infection
-Commensals , skin , vagina , under nails .
-Rarely sexually transmitted disease
-STD
Symptoms
-Pruritus vulvae
-Discharge → scanty
→ whitish.
→ cheesy, curdy ,sticky.
→ odorless .
-Dysuria , dysparopnia , soreness .
(>75% of women have once vag. candidiasis)
-Offensive odeur.
–Discharge →Profuse.
→yellowish green
→frothy mucoid
→ malodorous
–Pruritus , dysuria & dysparonia .
Signs
-Erythema & edema.
–Exocorian & skin fissures from itching .
-Characteristic discharge .
-Strawberry vagina .
–----Flea bittin cervix .
-Characteristic discharge .
TTT
Preventive : predisponig factors ﺲﻜﻋ
Curative :
-Alkaline vaginal Douches
-Antifungals :
local e.g, → nystatin 100,000 IU/d
→Miconazole 2oomg
Oral : fluconazole 150 mg
-Acidic vaginal douches
-The drug of choice :
metronidazole → 250mg t.d.s
or → 2gm single dose .
-TTT of sexual partner .

 
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Bacterial vaginosis
Causative organism
-Gardenella vaginalis
-Gm –ve bacilli .
Mode of infection
-Not STD
Symptoms
-Fishy odour after sexual intercourse –Discharge →Profuse.
→whitish or green
→ mucoid
→ fishy odour
-No vulval itching or irritation.
-During preg.: → PROM → preterm labor
Signs
-Characteristic discharge
Complications

treatment
-Acidic vaginal douches
-The drug of choice :
metronidazole → 250mg t.d.s
or → 2gm single dose .
-During pregnancy : clindamycin or ampicillin . 
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35. Acute cervicitis : causative organisms, symptoms, signs , treatment, sequalae (fate)
.(account).
Causative organisms
1. Gonococci (NG)
2. Chlamydia:
Symptoms
1- Purulent vaginal discharge with resulting vaginal irritation.
2- Sense of pelvic heaviness due to congestion.
3- Deep dyspareunia due to:
a- Pelvic congestion. b- Uterosacral affection. c- Parametrial affection.
4- Superficial dyspareunia due to associated vaginitis.
5- Backache (sacralgia) due to spread of infection through the uterosacral ligament.
6- Mild fever may occur.
signs
1- The cervix is swollen, red, soft, with pustules and yellowish or greenish mucopus
coming from the external os.
2- Marked tenderness on mobilizing the cervix.
3- Associated signs of the cause as in cases with gonorrhea.
Treatment
1 - Rest in bed, no intercourse, no instrumentation, light diet and laxatives.
2- Antibiotics: The CDC (1993) recommended the following regimen:
a- NG:
* Ceftriaxone 125mg IM single dose. OR
* Ofloxacin 400mg oral single dose. OR
* Cefixime 400mg oral single dose. OR
* Ciprofloxacin 500mg orally single dose,
b- Chlamydia:
* Doxycycline 100mg/12hrs orally for 7 days. OR
* Azithromycin Ig orally single dose. OR
* Ofloxacin 300mg/12hrs orally for 7 days. OR
* Erythromycin base 500/6hrs for 7 days. OR
* Erythromycin ethylsuccinate 800mg/6hrs orally for 7 days.
3- Treatment of all sexual contacts.

Sequalae (fate)
1- Spread to the upper genital tract and parametrium.
2- Chronicity with recurrent exacerbation.
3- 2
ry
acute vaginitis, or UTI.

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36. Chronic – non specific cervicitis: mode of infection & symptoms signs , complications,
treatment (cauterization and surgical treatment ).(account).
Mode Of Infection (AE) :
(The most important predisposing factor is non TTT of acute type)
-May be → infective : gonorrhea , Chlamydia , staph , strept, TB
→ non infective : post-operative as D & C and cauterization .
Symptoms
1. Vaginal discharge (the main complain).
2. Low back ache and sacralgia (due to spread of infection to uterosacral ligament)
3. Dyspareunia, dysuria, dyschazia, and dysmenorrhea.
4. Bleeding : Menorrhagia (pelvic congestion) or Contact bleeding .
5. Infertility.
Signs
1. Chronic endocervicitis.
2. Cervical ectopy "erosion".
3. Cervical ectropion. Bilateral cervical laceration with eversion of cervical lips.
4. Chronic hypertrophic cervicitis with barrel shaped cervix.
5. Mucous polyp.
6. Nabothian follicle or cyst formation.

Complications ???دﺎﻬﺘﺟا
1. Infertility 
2. Bleeding 
3. Cervical ectopy "erosion 
4. Cervical ectropion 
5. Nabothian follicle or cyst formation 

Treatment
1. Medical Treatment : Broad spectrum antibiotics , analgesics. vaginal antiseptics.
2.Cauterization: Indicated mainly in cervical erosion (discussed below).
3.Surgical: ectropion → trachelorrhaphy .
hypertrophic cervicitis → conization .
if the cervix is elongated and hypertrophied → amputation.



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37. Acute pelvic inflammatory diseases (PID) : definition – causative organisms , routes of
infection , diagnosis (symptoms ,signs ,DD, special investigations), differential diagnosis
,sequalae , treatment (medical & surgical) .(account). ً اﺪﺟ مﺎه
Definition
-Infection of the upper genital tract (above the internal os) , mainly salpingooophoritis +
Endometritis & Pelvic peritonitis.
-It is usually acute process except in cases of T.B. or actinomycosis it becomes a chronic PID.
Causative Organisms & Routes Of Infection :
-Most cases of acute PID are the result of a Ascending polymicrobial infection caused by :
1. Niesseria gonorrhea : →Most common (2/3 cases)
2. Chlamydia trachomatis: → 20 % of cases (the most common STD).
3. Other pathogens :
a. Aerobes : E. Coli, group B streptococci, staphylococci.
b. Anaerobes: Bacteroides and peptococci.
c. Genital mycoplasmas: M. hominis.
d. Tuberculous salpingitis : →It occurs via hematologic spread.
→Usually bilateral.
→Suspected if PID in virgins.

Diagnosis
Symptoms
1-Lower abdominal pain → 90 % of cases .
→ constant & dull ↑ by motion & sexual activity.
2-Menorrhagia → 40 % of cases .
3-Fever, cervical discharge
Signs
1-Lower abdominal tenderness
2-Tender cervical motion .
3-Adenexial tenderness.
Special Investigations
1. Pregnancy test: to rule out pregnancy complications eg. ectopic pregnancy.
2. Laboratory tests: leucocytic count, ESR and C-reactive protein.
3. Examination of the endocervix for inflammation, gram stain and culture .
4. Ultrasound → adnexial masses.
5. Endometrial biopsy → histologic endometritis.
6. Culdocentesis → pus .
7- Laparoscopy : Most accurate method + exclusion of other surgical emergencies.

Differential Diagnosis
1. Acute appendicitis. 2. Endometriosis.
3. Torsion or rupture of an adnexial mass. 4. Ectopic pregnancy.
5. Lower genital tract infection. 6. Cystitis.
 
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Sequalae
1-Infertility:
-PID is one of the major causes of infertility due to peritubal adhesions .
2-Ectopic pregnancy:
-↑The chance 6-10 folds peritubal adhesions.
3-Chronic pelvic pain :
-Chronic pelvic pain can be caused by hyrosalpinx or adhesions surrounding the ovary.
4-Hydrosalpinx and Pyosalpinx :
-Distension of fallopian tubes occur when both the fimbrial & interstitial ends are closed.
-This results in a retort shaped mass posterolateral to the uterus filled with fluid
(hydrosalpinx) or pus (pyosalpinx) which may communicate with an ovarian cyst resulting
in tuboovarian cysts or abscess.
5-Pelvic cellulitis (Parametritis)
-Inf. of the loose cellular tissue in the base of broad ligament lateral to Cx & upper vagina.
-Usually is caused by staphylococci or B. coli.
6-Suppurative thrombophlebitis of the pelvic veins : can result in septicemia.
7-Fitz Hugh Curtis syndrome:
-Perihepatic inflammation and adhesions that develop in 1-10% of patients with acute PID.
-It develop from vascular or transperitoneal dissemination of N Gonorrhea or C.trachomatis.
-Signs and symptoms includes : → Right upper quadrant pain & tenderness .
→ Pleuritic pain.
→ The condition is often mistakenly diagnosed as either
acute cholecytsitis or pneumonia.
8-Mortality :
-Mortality rate 5-10% for ruptured tubo-ovarian abscess or (ARDS).

Treatment
The therapeutic goals:
1. Elimination of the acute infection.
2. Treatment of symptoms.
3. Prevention of long term comp. such as infertility, ectopic preg. & chronic pelvic pain.
I-CDC Recommended Treatment for PID (Medical)
A-Regimens for outpatient therapy of acute PID:
Regimen A:
3
rd
generation Cephalsporin as Cefotoxime +Doxycycline lOOmg twice daily for 14 days.
Regimen B:
Ofloxacin 400mg twice daily oral for 14 days +Clindamycin 400mg oral four times /day
Ofloxacin 400mg twice daily oral for 14 days +Metronidazole 500mg twice daily
Criteria of Hospitalization:
1. Diagnosis is uncertain & surgical emergency such as appendicitis can not be excluded.
2. Pelvic abscess is suspected. 5- The patient is pregnant.
4. Adolescent patient.
5. The patient has HIV infection.
6. Severe illness or nausea and vomiting.
7. Poor response to initial outpatient therapy .
B-Regimens for inpatient therapy of acute PID:
Regimen A:
Cefoxitin 2gm IV. every 6 hours +Doxycycline lOOmg oral twice daily .
Regimen B :
Clindamycin 800mg IV. every 8 hours +Gentamycin 80mg/8 hours
**Either regimen should be continued for at least 48 hours after clinical improvement then
Doxycycline lOOmg/12 hours orally or Clindamycin 400mg 4 times to complete 14 d.
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II-Supportive TTT :
-Bed rest → best in Fowler’s position + hydration + no intercourse + analgesics .
III-Follow up :
-Re-evaluation after 2 to 3 days, if there is no response, hospitalization is mandatory & exclude
pelvic collections.
-Repeat cultures, the patient is cured if it is -ve after 2 weeks.
-TTT of the husband from STDs.

IV-Surgical Management of PID
-Should be indicated for patients with surgical emergencies such as:
1- Ruptured abscess.
2- Failed medical management.
-Laparascopy is usually helpful procedure for: D , TTT , culture .
-Definitive surgery should be delayed/or 2-3 months after the recent exacerbation, for
more complete resolution of the infection.
-TTT of pelvic abcess (ﺐﺘﻜﻳ)


38. Sexually transmitted diseases (STDs) : (MCQ ). T.B. female genital tract: (MCQ).

















39. Vaginal discharge : sources (vulva - vagina ,cervix – uterine – causes of physiologic
discharge & pathologic discharge.(MCQ).
 
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40. Infertility : causes of male infertility - causes of female infertility - coital errors leading to
infertility – special investigations to male factor – ovarian factor – tubal factor – uterine
factor – cervical factor .Symptoms suggesting ovulation .(account).
Causes of male infertility
1-Defective spermatogenesis :
General , hypothalamic & pituitary causes : as in amenorrhea .
Testicular causes :
Congenital : gonadal agenesis , gonadal dysgenesis , undescended testis .
Traumatic : direct trauma , varicocele → thermal trauma (controverse) , orchidectomy .
Inflammatory : TB , mumps
Neoplastic : e.g, seminoma
Post irradiation
2-Defective sperm transport :
Congenital : congenital absence of the vas deference. .
Traumatic : accidental ligation of the vas during surgery on inguinal hernia .
Inflammatory : TB , mumps
Neoplastic : e.g, prostatic hyperplasia → pressure from outside .
3-Defective sperm deposition :
1-Impotance : 90% psychogenic , 10% organic e.g, DM.
2-Premature ejaculation .
3-Retrograde ejaculation (ejaculation in urinary bladder e.g, DM)
4-Hypospadius & epispadius .

Causes of female infertility
General causes
1-Age : female fertility reaches maximum around 25 Y & ↓ sharply after 40Y .
2-Obesity : excessive obesity → less ovulation .
3-Environmenntal toxins : → less ovulation . e.g, lead, pesticides, smoking & alcohol .
4-Women's sexual disorders : e.g, vaginismus , frigidity & anorgasmia .
5-Immediate post coital vaginal douching .

Vaginal factor
1-Congenital : e.g, vaginal aplasia , transverse vaginal septum .
2-Traumatic : gyntresia.
3-Inflammatory : vaginitis .
4-Functional : any factor leading to hostile vagina .

Cervical factor
A-Organic :
1-Congenital : e.g, cervical atresia , cervical stenosis .
2-Traumatic : → post cauterization , conization , amputation & fothergill's operation .
3-Inflammatory : chronic cervicitis .
4-Neoplastic : → cancer cervix .
→ cervical polyp or fibroid .
B-Functional :
1-Immunological : antibodies against sperm in cervical mucous.
2-Hormonal : ↓ estrogen whether estrogen deficiency or antiestrogenic effect of clomiphene
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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Uterine factor
1-Congenital : e.g, aplsia or hypoplasia .
2-Traumatic : → hysterectomy
→ Asherman's syndrome .
3-Inflammatory : TB , bilharziasis .
4-Neoplastic : fibroids , endometriosis see oncology . (ﺐﺘﻜﺗ)
5-Displacement : prolapse , RVF .
6-Immunological : antibodies against sperm or early developed zygot .

Tubal factor
→ Tubal causes of tubal ectopic pregnancy :


N.B : most common causes of adhesions are previous laparatomy , PID , endometriosis .
Tubal factor is the most common cause of 2ry amenorrhea .
Ovarian factor (ovulation dysfunction)
1-Anovulation .
A-Physiological : prepubertal , postmenopausal , pregnancy & lactation → as amenorrhea (ﺐﺘﻜﺗ)
B-Pathological : general , hypothalamic , pituitary , ovarian causes of amenorrhea (ﺐﺘﻜﺗ).
According to gonadotrphins , causes are classified into :
1-Hypogonadotrophic : hypothalamic & pituitary causes.
2-Hypergonadotrophic : ovarian causes .
3-Eugonadotrophic : PCOS .
2-Luteal phase defect (defects of corpus luteum) .
1-Defective follicular growth
2-Decreased FSH in the follicular phase of the cycle.
3-Decreased FSH and LH at the time of ovulation.
4-Hyperprolactinemia.
5-Hyperandrogenemia.
6-Hypothyroidism.
7-Treatment with ovulatroy drugs (Clomiphene citrate).
8-Pelvic endometriosis (Luteolytic effect of PGs).
3-Lutenized unruptured follicle .
→ Pelvic endometriosis.
→ Women using prostaglandin synthetase inhibitors.

Coital errors leading to infertility
1. It may be due to problems of coital frequency:
1) Infrequent sexual intercourse (less chance of sperms being available to the egg – during ovulation)
2) Frequent intercourse (several times a day) due to the misconception that it will help conception.
This lowers sperm count. This impact is greater on men with marginal fertility. Normal counts
generally are not lowered into the infertile range by daily ejaculation.
2. Errors in sexual techniques may result in infertility:
1) Intravaginal use of lubricants due to weak spermicidal nature.
2) Frequent douching makes the vaginal environment hostile to sperm.
3) Improper coital postures reduce the number of sperms that reach the mouth of the cervix
4) Not waiting in place after ejaculation.
5) Extravaginal ejaculation
3. Others: dysparunia - no lipido or orgasm
flower semins marital dyshamony
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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Special investigations to :
Male factor
1-Semen analysis
**Collection of the sample : → 3 days abstinence (no sexual intercourse)
→ Obtain sample by masturbation or coitus interruptus
→ Don't use condom as they contain spermicidsal
**Criteria of normal semen analysis :
A-Macroscopic :
-Volume : 3-6/ejaculate. -Reaction : alkaline.
-Colour : grayish white -Odour: with specific odour.
-Consistency : viscid , liquefies after 20 minutes .
B-Microscopic :
-Count : >20 milions/ml.
-Motility : >40% motile after 1
st
hour (forward progressive motility) .
-Abnormal forms : < 50% .
-RBCs : 0-3 cell /HPF .
-Pus cells : 0-3 cell /HPF .
C-Biochemical : → Fructose level.
→ PGs level .
**Criteria of abnormal semen analysis :
-Aspermia → no semen . -Azospermia → no sperms.
-Oligospermia → count <20 mil/ml . -Polyspermia → count >200 mil/ml.
-Asthenospermia → weak motile sperms.
-Teratospermia → abnormal forms >50% . -Necrospermia → dead sperms.
-Hematospermia → ↑ RBCs >3 cell /HPF.
-Pyospermia → ↑ pus cells >3 cell /HPF.
2-Testicular biopsy : indicated in azospermia .
-To differentiatre ( ) : Defective soermatogenesis (non obstructive) → no sperms .
Defective transport (obstructive) → sperms .
3-Culture & sensitivity test : indicated in pyospermia .
4-Hormonal assay : FSH & LH , testosterone , prolactin .
5-Doppler US : for varicocele .
6-Karyotyping .
7-Sperm antibodies in plasma .

Ovarian factor
a) Investigations of ovulation :
Direct : → transvagival folliculometry
→ laparoscope
Indirect : → physiologic : basal body temperature
→ morphological : PMEB , cervical mucous , vaginal cytology
→ hormonal assay : midluteal progesterone , midcycle E2 & LH .
** Transvaginal folliculometry : (TVF)
→ TVS for assessment of follicular growth & ovulation .
→ Ovulation is diagnosed when the dominant follicle (18-25 mm) collapses + free fluid
in Douglas pouch .
→ Timing depends on course of ttt e.g, with clomiphene from day 9 every other day .
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** Laparascope :
→ To visualize stigmata of ovulation .
** Basal body temperature : (BBT)
→ Depends on thermogenic effect of progesterone .
→ ↑ temp. 0.3-0.5 º in 2
nd
half of the cycle (biphasic chart) → suggestive of ovulation.
→ Unreliable test : any other cause can elevate temp. in 2
nd
half e.g, infection .
** Premenstrual endometrial biobsy : (PMEB)
→ Secretory endometrium : suggestive of ovulation .
→ Proliferative endometrium : anovulation.
** Vaginal cytology : (in the 2
nd
half of the cycle)
→ Progestational : suggestive of ovulation .
→ Estrogenic: anovulation.
** Cervical mucous study : (in the expected time of ovulation)
→ Estrogenic : suggestive of ovulation .
→ Progestational : anovulation.
** Midluteal progesterone : (the most accurate test)
→ <3ng/ml → anovulation .
→ >15 ng/ml → suggestive of ovulation.
→ 3-15 ng/ml → ovulation , anovulation or luteal phase defect .
** Midcycle LH : → ↑ 3 folds more than original value → suggestive of ovulation.
** Midcycle E2 : → >200 pico gm/ml → suggestive of ovulation.
b) Investigations of Luteal Phase Defects → Short luteal phase by BBT chart.
→ Mid luteal serum progesterone (on 21
st
day of the cycle) <5ng/ml.
→ Lag of 2 days or more on secretory changes of the PMEB
Tubal factor (Tubal patency tests اﺪﺟ مﺎه)
A-Hysterosalpingography : (HSG)
Principle :
-Injection of radiopaque dye inside uterus to pass to the peritoneal cavity throughout
patent tubes .
-2 films must be taken :
→ immediate film after injection of dye to evaluate uterine cavity & patency of tubes .
→ delayed film for pelvic smearing .
-The used materials :
→ urographin : water soluble .
→ lipidol : fat soluble (better as it gives good contrast & chance for pelvic smearing)
Timing :
- 3-4 days post-menstrual → exclude pregnancy
→ ↓ incidence of endometriosis
→ ↓ incidence of embolisation .
→ before menstruation , endometrium is thick & may obstruct
uterotubal ostea → false –ve result .
Contraindications :
Absolute → pregnancy .
→ acute PID.
Relative → menstruation (risk of embolisation & endometriosis)
→ premenstrual : pregnancy , thick secretions .
→ allergy to dye
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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Complications :
→ Shock . → Hemorrhage .
→ Infection . → Perforation .
→ Embolisation → Endometriosis .
→ Allergy . → Rupture of hydrosalpinx
Value or advantages :
A-Diagnostic :
In tubal factor : diagnosis of :
→ tubal patency . → tubal stenosis .
→ salpingitis isthmica nodusa . → Hydrosalpinx .
→ Peritubal adhesions . → tubal obstruction (can detect site & side).
In uterine factor : diagnosis of :
→ Congenital anomalies of the uterus . → Intruterine adhesions .
→ RVF . → Missed IUD .
→ Fibroids . → Polyps .
In cervical factor : diagnosis of :
→ Cervical stenosis , incompetence or polyp .
B-Therapeutic :
→ Overcome fimbrial stenosis .
→ Overcome tubal spasm .
→ Breakdown of thin tubal adhesions .
→ Breakdown of mucous plug obstructing the tube .
→ Straightening of tortuous kinked tube .
→ Psychological factor.
Disadvantages :
→ High false positive results in diagnosis of tubal block (transient tubal spasm) .

B-Laparascopy :
-As a tubal patency test → injection of methylene blue into the cervix → visualize the dye
from fimbrae by laparascope .
-Complementary to HSG as it shows tube from outside , unlike HSG (from inside) .
C-Sonohystrography :
-Injection of saline through cervix followed by TVS to detect free fluid in Douglas pouch.
d-Hystroscope : visualization of the ostea of the tube .
e-Salpingoscopy

** Old tests :
1-Rubin's test : (insufflation test)
2-Sharman's test : (kymography)
 
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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Uterine factor
as investigations of the uterine factor of amenorrhea:
-Radiological : US , MRI pelvis , HSG
-Laparascope & hystroscope .
-Karyotyping
-Hormonal assay : LH , FSH , testosterone levels.
-Endometrial sampling .
-Uterine sound
-Progesterone challenge test + estrogen & progesterone withdrawal test .

Cervical factor
as investigations of the uterine factor of amenorrhea .
1-Post coital test :
-Aim : examine the ability of the sperm to to reach & survive in cervical mucous.
-Timing : at time of ovulation .
-Procedure :→ abstinence for 3 days
→ sexual intercourse 48 h before ovulation .
→ within 2-12 h after intercourse take vaginal & cervical sample .
-Results :Vaginal sample → no sperms → failure of deposition , azoospermia .
→ dead sperms → hostile vaginal secretion , necrospermia .
→ shaking movements → immunological infertility.
Cervical sample → >20 progressively motile sperms /HPF → normal .
→ <5 /HPF → hostile cervical mucous , asthenospermia .

2-Culture & sensitivity test : in infections .
3-Serology & antibody assay : in immunological .
4-Biochemical & physical studies of cervical mucous .

Symptoms suggesting ovulation :
1. Midcyclic spotting
2. Mid-cyclic pain (Mittelschmerz) including pinch/cramps
3. premenstrual mastalgia .
4. ↑ temp. 0.3-0.5 º in 2
nd
half of the cycle (biphasic chart) (basal temperature shift)
5. fertile cervical fluid (Changes in vaginal discharge)

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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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41. Anovulation : causes , special investigations, treatment (general treatment , induction of
ouvulation –,surgical treatment ).(account). اﺪﺟ مﺎه
Causes ٦١ ص ﻖﺑﺎﺴﻟا لاﺆﺴﻟا ﻲﻓ ﺔﺑﺎﺟﻻا
Special Investigations ﻖﺑﺎﺴﻟا لاﺆﺴﻟا ﻲﻓ ﺔﺑﺎﺟﻻا ص ٦٢ ، ٦٣
Treatment
General Treatment
- ttt of the cause .

Induction Of Ouvulation
Prerequisites :
1-Documentation of anovulation .
2-Invstigations for other factors including male factor.
3-Patency of fallopian tubes is confirmed .
4-(+ve) progesterone challenge test indicating adequate levels of endogenous E2 .
Drugs :
1-Clomiphene citrate : (clomid)
Mech. of action : (antiestrogenic effect)
-Competitive inhibition of estrogen receptors in hypothalamus & pituitary → false
impression of ↓ estrogen → ↑ FSH & LH from pituitary → ovulation .
Indications :
-Infertility due to anovulation . –PCOS
-LPD -ART
-With corticosteroids to (--) excess adrenal androgens -Post pill amenorrhea
Dose : (tablet → 50mg)
- 1 X 2 X 5 , starting 3
rd
- 5
th
day of the cycle . ( & follow up by TVF 1 day after)
- If no response ↑ dose till 1 X 5 X 5 , if no response → Clomephine resistance , so add
corticosteroids , HCG , HMG , GnRH analogues
Side effects : 3 GHAD
-GIT upset -Galactorrhea -Multiple gestation
-Headache -Hot flushes -Hyperstimulation syndrome
-Alopecia - ↑ risk of abortion -Antiestrogenic effect on Cx
-Dysmenorrhea -Depression -Defcet in CL (LPD)
Contraindications :
-Pregnancy . –Liver disease -Ovarian cysts
Results :
-Ovulation rate : 70-80 % -Pregnancy rate : 40%
-The difference is due to : → Anti-estrogenic effect on cx. mucous → impermeable .
→ LPD
→ Improper coitus timing
→ Other factors of infertility
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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2-Cyclophenil :
-Chemically as clomephine but no antiestrogenic effect → less effective +less side effects
3-Tamoxifen :
-Has antiestrogenic effect → used for clomiphene failure .
4-Human menopausal gonadotrophins :
Composition : → Mixture of FSH (75 IU) + LH (75 IU)
Mech. of action : → Direct stimulation of growth of the follicles .
Dose : no fixed dose
- May be 2 ampoules on days 3,5,7 or 4,6,8 ( & follow up by TVF 1 day after).
Side effects : → Multiple pregnancy
→ Hyperstimulation syndrome
Results : → Pregnancy rate : 60 – 80 % within 6 cycles .
N.B : other gonadotrophins used : recombinant FSH & LH , HCG , pure FSH .
5-GnRH analogues : in a pulsatile manner .
6-Combined therapy:
-Clomiphene + HMG .
-Clomiphene + HCG .
-Clomiphene + bromocreptine (in cases of hyperprolactinemia) .

Surgical Treatment
-Surgical TTT in PCOS . (see amenorrhea)
-Removal of any virilizing ovarian tumor .
-Removal of prolactinoma .

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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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42. Polycystic ovarian syndrome (PCOS): clinical picture, sonographic picture, hormonal
profile, , laparoscopy, - pathology of the ovaries and endometrium- treatment (general,
medical, surgical) – long term sequealae .(account). اﺪﺟ مﺎه
Clinical picture
- Hirsutism , amenorrhea or oligomenorrhea , obesity , acne , infertility. (HAOAI)

Sonographic picture
- TVS : multiple subcapsular follicles(2-8mm) → necklace appearance + ↑ stromal volume
hormonal profile
→ ↑ LH/FSH ratio → ↑ androgens & ↓ SHBG
→ ↑ free estrogen → ↑ insulin
Laparoscopy
- polcystic ovaries (PCO)

Pathology of the ovaries and endometrium
Pathophysiology : (not completely understood)
Hyperinsulinemia or dysfunction of hypothalamo - pituitary ovarian axis →
Ovarian androgens → some is converted into E1 → (+ve) feed back with LH +(-ve) feed
back with FSH : low FSH → follicle formation with no maturation → no ovulation .
High LH → (++) theca lutin cells to secrete androgens (vicious circle)
Ovaries: N/E:
thickened, smooth, pearl-white outer surface of the ovary
Ovarian cysts : These "cysts" are actually immature follicles, not cysts ("polyfollicular ovary
syndrome" would have been a more accurate name). The follicles have developed from
primordial follicles, but the development has stopped ("arrested") at an early antral stage due
to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery,
appearing as a 'string of pearls' on ultrasound examination
Endometrium:
endometrial hyperplasia
Treatment
General
Medical treatment of PCOS is tailored to the patient's goals. Broadly, these may be considered under four
categories:
 Lowering of insulin levels
 Restoration of fertility
 Treatment of hirsutism or acne
 Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer
So If :
A-If don't want children :
- Obesity → weight reduction
- Menstrual disturbances → cyclic progesterone or COCs
- Hirsutism & acne → androgen receptor blockers
- Hyperinsulinemia → metformin .
B-If want children : (infertility)
-Weight reduction
 
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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44. Luteal phase defect : definition ,causes ,special investigations, treatment (luteal support)
.(account). ﻹا ﻦﻣ ءﺰﺟ لاﺆﺴﻟا ﻲﻓ رﺮﻜﻣ ﺔﺑﺎﺟ ٤٠
Definition : Deficiency of progesterone secretion from the corpus luteum which may result
from premature degeneration of CL or from insufficient progesterone secretion.
C
a
u
s
e
s

1-Defective follicular growth
2-Decreased FSH in the follicular phase of the
cycle.
3-Decreased FSH and LH at the time of
ovulation.
4-Hyperprolactinemia.
5-Hyperandrogenemia.
6-Hypothyroidism.
7-Treatment with ovulatroy drugs (Clomiphene
citrate).
8-Pelvic endometriosis (Luteolytic effect of
PGs).
Special investigations
→ Short luteal phase by BBT chart.
→ Mid luteal serum progesterone (on 21
st
day of the cycle) <5ng/ml.
→ Lag of 2 days or more on secretory changes of the PMEB
Treatment (luteal support)
1. Clomiphene citrate and hMG : to improve the quality of the follicular growth.
2. Progesterone supplementation:
a. Orally: micronized progesterone.
b. Vaginal suppositories : 25mg twice daily starting on the 3
rd
day after ovulation.
c. 17-hydroxy progesterone caproate 250mg IM/weekly.
If pregnancy occurred continue till 12 weeks.
3. Human chorionicgonadotrophin (hCG) :
-2500 IU/3 days starting on the 3
rd
day after ovulation.
-If pregnancy occurred continue till 12 weeks.
4. Bromocriptine: if associated with hyperprolactenimia


45. In vitro fertilization and embryo transfer (IVF _ ET): principle, indications, technique
(lines of the procedures) , prognosis (MCQ).








46. Intracytomplasmic sperm injection ( ICSI ): principle, indications (MCQ).Intrauterine
insemination (IUI) : principle, indications.(MCQ).
 
Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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47. Intrauterine contraception device (IUCD): types, modes of action – indications and
contraindications - technique of insertion, timing of insertion ,side effects and
complications : bleeding disorders related to IUCD ( patterns, ttt)- pelvic infection related
to IUCD ( causative organism , C/ P, ttt)– pregnancy related to IUCD (rate, types ,
diagnosis, ttt) .(account).
Types
1-Non medicated IUD : (inert)
-Obsolete now .
-Polyethelene & barium only .
- May be : → Lippes loop → double S-shaped with 2 nylon threads
→ less effective
→ inserted by pushing technique (high incidence of perforation) .
→ life long
→ safe T-coil & Dalkon shield.
2-Medicated IUD : (active)
-They are the used IUDs now .
-Polyethelene & barium + loaded with certain material .
- May be :
1-Cupper medicated → Types → cupper T : T2oo , T220 , T380 A (most used)
(number represent surface area of cupper wire)
→ cupper 7 : 200
→ multiload : 350 , 375
→ cupper & silver : nova –T
→ more effective.
→ inserted by withdrawal technique (less incidence of perforation) .
→ duration for 10 years .
2-Progesterone medicated (merina) (IUS) → T-shaped with progesterone in vertical limb
→ duration of action 5 y
3-Anti-fibrinolytic medicated .

Modes of action
A-Polyethelene & barium components :
1-Local sterile inflammatory reaction in the endometrium : leading to
→ swollen , edematous , devitalized endometrium not suitable for implantation.
→ ↑ acidity in the endometrium → hostile for the sperms & early developed zygote.
→ ↑ macrophage w' engulf sperm or early developed zygote .
→ leucocytic infiltration .
2-Local Pgs release : , leading to uterine contractions , w' will lead to :
→ prevention of implantation of early developed zygot.
→ expulsion of early implanted ovum .
3-Mechanical factor : produces dislodgement of the zygote .
B-Medications :
1-Cu : → ↑ the local sterile inflammatory reaction .
→ ↑ macrophage release .
→ disturb the enzymes , glycogen metabolism of endometrial cells needed for growth of implanted zygote .
→ silver : ↓ fragmentation of Cu → prolongation of the life span of IUD .
2-Progesterone : → as a contraceptive : peripheral action of POPs .
→ as a TTT of DUB : see DUB .
3-Antifibrinolytics : → ↓ bleeding with IUD. 
   
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Indications
A-Contraceptive use :
1- In multipara having children (never in nulligravida as it causes PID) .
2-Females > 35 years .
3-Females refusing hormonal contraception .
4-In lactating females .
B-Non contraceptive use :
1-DUB , by : progesterone & antifibrinolytic medicated IUD.
2-After adheseolysis in Asherman's syndrome (only indication of Lippe's loop nowadays).
Contraindications
A-Absolute : (WHO Medical Eligibility Criteria for starting (IUD) category 4 )
1-Pregnancy.
2-Unexplained vaginal bleeding.
3-Cervical , endometrial or ovarian cancer.
4-Current or recent PID , STDs , septic abortion or pelvic TB.
5-Distorded uterine cavity.
B-Relative : (WHO Medical Eligibility Criteria for starting (IUD) category 3 )
1-Risk of developing STDs .
2-HIV/AIDS infection.
Technique of insertion
-Pushing technique : with Lippes loop → high incidence of perforation .
-Withdrawal technique : with other types → ↓ incidence of perforation .
Timing of insertion
-During the last few days of menstrual cycle → exclude pregnancy.
→ Cx. is still opened → easy painless insertion.
→ spotting after insertion mistaken as menses.
-Inserted at any time provided that the pregnancy is surely excluded.
-Immediate postpartum: after delivery of placenta in normal labour or CS (need experience).
Advantages → Cx is fully dilated , so no pain .
→ spotting after insertion mistaken with luchia .
Disadvantages → ↑ incidence of infection & inflammation .
→ ↑ incidence of displacement & perforation .
-Delayed postpartum: after at least 4 w after vaginal delivery or CS or abortion.
Schedule
-Removed after expiry date e.g, in Cu-T 380 A → 10 years .

Side effects & Complications :
(risks) (complications) 5P 2I 2E 2D
P → Pregnancy → PID → Perforation → Pain → Bleeding & Amenorrhea
I → Inability to feel the threads (missed loop)
→ Insertion complications : → vaso-vagal attack → perforation → failure of insertion
E → Expulsion
→ Extraction difficulties (see missed IUD)
D → Discharge serous , serosanginous or mucous .
→ Discomfort of male e.g very long threads

Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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Bleeding disorders related to IUCD (Menstrual disturbances)
A-Bleeding:
-Commonest complication mainly menorrhagia .
-Cause : IUD disturb PGs → 2ry DUB . Or local causes e.g, polyp .
-TTT : exclude local causes then deal as 2ry DUB may give progesterone medicated IUD
B-Amenorrhea :
-IUD + amenorrhea → pregnancy until proved otherwise & this pregnancy is ectopic
till proved otherwise.
TTT -If pregnancy excluded → it is a case of 2ry amenorrhea & IUD has no role .
Treated as 2ry amenorrhea
Pelvic infection related to IUCD :
-IUD ↑ risk of PID 1.5 times more than normal (especially in 1
st
month after insertion) .
-Cause & causative organism → septic IUD
→ safety threads act as a ladder for microorganisms
→ Pelvic Actinomycosis Israeli
-C/P : لاﺆﺳ ﻲﻓ دﺎﻌُ ﻣ ٣٧
Symptoms
1-Lower abdominal pain → 90 % of cases .
→ constant & dull ↑ by motion & sexual activity.
2-Menorrhagia → 40 % of cases .
3-Fever, cervical discharge
Signs
1-Lower abdominal tenderness
2-Tender cervical motion .
3-Adenexial tenderness.
-Complications : tubal adhesions → infertility (never used in nullipara)
-TTT : loop extraction & ttt of PID . لاﺆﺳ ﻲﻓ دﺎﻌُ ﻣ ٣٧
Pregnancy related to IUCD
Rate
(1/30 pregnancies)
-IUD + amenorrhea → pregnancy until proved otherwise & this pregnancy is ectopic till proved otherwise
Types
- extrauterine → ectopic pregnancy → deal as ectopic pregnancy .
- intrauterine → pregnancy on top of IUD
Causes → perforation
→ expulsion
→ low insertion of IUD
→ expiry
→ congenital anomalies of the uterus e.g, bicornuate uterus .
Risks → abortion : septic abortion till proved otherwise.(50%)
→ preterm labor (4 times ↑ risk)
→ no ↑ risk of congenital anomalies .
Diagnosis
IUD + amenorrhea → pregnancy until proved otherwise & this pregnancy is ectopic
+other symptoms & signs of ectopic pregnancy or Normal pregnancy ??
ttt
→ if threads are accessible : immediate removal & follow up (↓ risk of abortion to 25 %).
→ if not accessible : leave IUD & follow up as high risk pregnancy .
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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48. Combined oral contraceptives : (COC) hormone components , indications, side effects
complications – contraindications – non contraceptive benefits .Progestin only pills (POP) :
mode of action – indications – side effects.. Injectable contraceptives: types, hormone
components - side effects. Subdermal implant : types , hormone component - side effects.
Post coital contraception (emergency contraception )indications, methods .Post partum
contraception : methods .(account).
Combined oral contraceptives : (COC)
Hormone components
1-First generation :
50 µg EE2 (ethinyl estradiol) + 1
st
generation gestagens [NET (norethisterone) family]
2-Second generation :
30 -35 µg EE2 (ethinyl estradiol) + 2
nd
generation gestagens [LNG (levonorgestril) ]
3-Third generation :
20 -30 µg EE2 + 3
rd
generation gestagens [desogestril , norgestimate, gestodene]
Indications
A-Contraceptive use :
→ in females 20 -35 years if not contraindicated .
B-Non contraceptive use :
1-DUB. 2-Endometriosis.
3-Spasmodic dysmenorrhea. 4-PMS.
5-Hairsuitism 6-Acne.
7-Functioning ovarian cyst 8-To postpone menstruation .
Side effects & complications
1-On pregnancy :
-Teratogenic if given in 1
st
trimester causing anomalies in (Vertebral bodies , Anorectal ,
Cardiac , Tracheal , Renal , Esophogeal , Limb) → VACTREL .
2-On breast :
-Suppression of lactation . – Breast tenderness
-↑ incidence of cancer breast . -↓ incidence of benign breast lesions .
3-Menstrual disturbances :
A-Breakthroug bleeding: (inter menstrual bleeding)
-May be → irregular intake of pills → exclude it .
→ local lesion → exclude it.
-Shift to triphasic pills or POPs or long acting injectables .
B-No withdrawal bleeding : (after stopping the pills)
-May be → pregnancy → exclude it .
→ severe exhausted atrophied endometrium → shift to another COCs with
higher dose of estrogen .
C-Hypomenorrhea :
→ shift to another COCs with higher dose of estrogen .
D-Post pill amenorrhea :
-Def. : no menstruation for 6 months after stopping COCs .
-Cause → persistent (--) of hypothalamo-pituitary- ovarian axis .
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→ pituitary prolactinoma
-Predisposing factors : females alrerady having oligomenorrhea .
-TTT : → deal as a case of 2ry amenorrhea .
→ to get pregnant : ovulation induction .
→ to regulate the cycles : cyclic estrogen & progesterone .
4-Metabolic effects :
-Proteins : anabolic → ↑ weight . (E2)
-CHO : diabetogenic . (E2)
-Fat : ↑ LDL & ↓ HDL . (prog)
-H2O : salt & water retention → ↑ weight . (E2)
-Clotting : ↑ clotting . (E2)
5-CVS effects :
-E2 → ↑ incidence of thrombosis , salt & water retention .
-Progesterone → ↑ incidence of atherosclerosis .
So, patient is more liable to → HTN
→ IHD
→ Pulmonary embolism
→ DVT
→ Systemic vascular occlusions
6-CNS effects :
- ↑ incidence of headache , migrane & mood changes .
- ↑ incidence of cerebral strokes .
7-GIT effects :
- Nausea , vomiting & malabsorption .
- Liver & gall bladder : → ↑ gall stone formation .
→ ↑ cholecystitis.
→ ↑ incidence of hepatic tumors
8-Anticosmotic effect :
-Weight gain.
-Alopecia .
-Skin pigmentation .
-Acne .
9-On fertility :
- Delayed 3 months after stoppage of pills .
10-Pseudopregnancy state :
- Nausea, vomiting, headache, dizziness (E2) loss of appetite , depression (prog.) .
11-Oncogenic effect :
- ↑ incidence of cancer breast if used before 36 years .
- ↑benign & malignant tumors of the liver .
- HDP : ↑ incidence of fibroids & endometriosis.
- The risk of invasive cancer cervix ↑ after 5 years of use of COCs (may be due to
other factors e.g, smoking & multiple sexual parteners)
12-Drug interaction :
- Drugs that ↑ activity of hepatic microsomal enzymes → ↑ destruction E2 & Prog .
→ ↑ failure rate e.g, rifampicin , tetracycline , sedatives , hypnotics .
- ↓ of : → anticoagulants.
→ oral hypoglycemics.
→ antihypertensives.

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Contraindications :
A-Absolute : (WHO Medical Eligibility Criteria for starting (COCs) category 4 )
1. Pregnancy.
2. Heavy smokers.
3. Breast cancer.
4. Breastfeeding less than 6 weeks after childbirth .
5. Unexplained vaginal bleeding .
6. Complicated diabetes.
7. Severe hypertension.
8. Current or past history of ischemic heart diseases.
9. Current or past history of thromboembolic disorders.
10. Valvular heart diseases with complication.
11. Past thrombo-vascular accidents.
12. Prolonged immobilization.
13. Migraine.
14. Epilepsy.
15. Active liver disease, cirrhosis, liver tumours.
B-Relative : (WHO Medical Eligibility Criteria for starting COCs category 3 )
1. Age 35 and more.
2. light smoker.
3. Breastfeeding women 6 weeks to 6 months after childbirth.
4. Non breastfeeding women during first 3 weeks after childbirth.
5. Mild and moderate hypertension.
6. Current treatment with antibiotics (rifampin, griseofulvin) or antiepileptic drugs.
7. Gallbladder disease.
Non contraceptive benefits
1-DUB. 2-Endometriosis.
3-Spasmodic dysmenorrhea. 4-PMS.
5-Hairsuitism 6-Acne.
7-Functioning ovarian cyst 8-To postpone menstruation .
Progestin only pills (pop)
Mode of action
A-Peripheral : → hostile cervical mucous not suitable for penetration .
→ atrophic endometrium not suitable for implantation .
→ ↓ motility of the tubes.
B-Central : → (-ve) feedback with LH → (--) ovulation (anovulation) .
Indications
Contraceptive use :
→ in lactating mothers .
→ if the age >35 y
→ if COCs is contraindicated .
Side effects
1-Menstrual disturbances :
-In the form of amenorrhea , oligomenorrhea , irregular uterine bleeding .
2-↑ incidence of ectopic pregnancy :
-↓ motility of the tubes .
3-Weight gain & depression .
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Injectable contraceptives
Types & hormone components :
Progesterone only injectables (long acting injectables)
1-Depot-provera → DMPA (depot medroxy progesterone acetate) : 150 mg , every 3 months
2-Noristerat → NET-EN (nor ethisterone enanthate) : 200 mg , every 2 months
Combined injectables
1- Cyclofem → 25 mg DMPA + 5 mg E2 cypionate , every 1 month .
2- Mysegyna → 50 mg NET-EN + 5 mg E2 valerate , every 1 month .
side effects
Progesterone only injectables (long acting injectables)
1-Menstrual disturbances : (most common & the main cause to discontinue)
-In the form of amenorrhea , heavy prolonged bleeding , irregular uterine bleeding .
-TTT of breakthrough bleeding → exclude local causes
→ Estrogen : EE2 or primarin
→ COCs
→ if no response : Shift to other method

2-Fertility : may be delayed 4 months more than other causes

3-Pregnancy : on female baby → pseudo hermaphropdite .

4-↓ Denisty of the bone .

5-Breast enlargement & mastodenia .

6-Weight gain & depression .

7-Carcinogenesis : (controverse)
-Overall incidence is not increased , but ↑ may be due to early diagnosis since regular
visits or pre-existing breast cancer .
Combined injectables :
As COCs لاﺆﺴﻟا ﺲﻔﻧ ﻲﻠﻋا ﻲﻓ ﺔﺑﺎﺟﻹا
Subdermal implant
Types & Hormone component
1-Norplant :
→ 6 match sized capsules
→ Gestagen : levonorgestrel .
→ Duration : 5 years .
2-Implanon :
→ 1 rod capsule 4cm X 2mm.
→ Gestagen : etonogestrel (3 keto desogestril) in a rate of 40 mg/day.
→ Duration : 3 years .
3-Javelle : as norplant but 2 rods

 
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Side effects
1-Menstrual disturbances : (most common & the main cause to discontinue)
- As long acting injectables .
2-Breast enlargement & mastodenia .
3-Weight gain & depression .

Post coital contraception (emergency contraception )
Indications
1-Rape.
2-ruptured condom
3-Unprepared intercourse
Methods
A- Immediate (within 1
st
3 days for optimal efficacy)
1-Post-coital douchings :
-By : 50% aceto-acetic acid or antiseptic solution .
-The aim is to kill the sperms in the vagina .
2-IUD : → It prevents implantation of ovum .
→ highly effective (0.1 % pregnancy rate)
3-Emeregncy contraceptive pills : (ECPs) (the sooner the more effective)
-COCs : (Yuzpe regimen) → each dose 0.1 mg EE +0.5 mg LNG ( 4 tablets of standard low
dose pills) then repeat / 12 h
→ mech. : as COCs
→ less effective (57% )

-POPs : → 1
st
dose 0.75 LNG then repeated / 12 h
→ mech. : as POPs
→ more effective (85% )
-Large dose estrogen 5mg/day for 5 days . It inhibits ovulation .
4-LHRH : under trial

B- Early (within 3-7 days)
1-IUD :
2-PGs : Acts by producing luteolysis or blocking ovulation .
3-Danazol : under trial

C- Late (after 1 week)
1-IUD :
2-PGs :
3-Antiprogesterone : mifeprostone (RU-486) .

 
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Post partum contraception
Methods
1.Methods of first choice: (can be used immediately)
a. Barrier methods.
b. IUDs.
c. Female sterilization. (PPTL) → Postpartum tubal ligation
d. Natural family planning.
2.Methods of second choice :(not to be used before 6 weeks after delivery)
a. POPs.
b. Progestin only injectables.
c. Sub-dermal implants.
d. Hormone releasing IUD (IUS ).
3.Methods of third choice: (not to be used before 6 months after delivery)
a. COCs. As it decrease milk production to baby.
b. Combined monthly injectables.

49. Spermicidals .(account) - Safe period (Abstinence) , coitus interruptus , Breast feeding :
lacational amenorrhea ) as contraception. Condom: male & female : condom , material ,
advantages, disadvantages. Sterilization : approaches & techniques (principles). (MCQ).
Spermicidals
Description : 2 parts
- Active agent : usually nonoxynol-9 . Spermicidal or spermistatic by :
→ osmotic imbalance
→ inactivation of the enzymes essential for sperm motility & fertilization .
- Base : responsible for the form of spermicide e.g, cream , foam , tablet .
How to use : (precautions)
-They are put in the vagina few minutes before sexual intercourse then allow intercourse .
-No vaginal douching for 4 hours after intercourse to allow spermicides to work .
Advantages :
1-Geneal : as usual but not effective .
2-Protection against STDs as it has bactericidal action.
Disadvantages :
1-Highest failure rate .
2-Usually used as adjuvant method with the condom or vaginal diaphragm .
3-Chemical vaginitis & ulceration .


50. Swellings of the vulva : MCQ
 
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Dr.Moslim Obs&Gyn Answers Guide   Gynecology
 
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51. Vulva intraepithelial neoplasm( VIN): grades, clinical picture , special investigations ,
treatment.Cancer vulva: Incidence, high risk factors (predisposing factors), sites,
pathologic features (N/E + M/E), Spread, FIGO staging, diagnosis, pre- Operative
investigations, treatment of stage I, II, III & IV. Vulvectomy: types, components ,
indications. (account).
Vulva intraepithelial neoplasm ( VIN)
Grades
-Mild dysplasia (VIN I)
-Moderate dysplasia (VIN II)
-Severe dysplasia (VIN III)
.
Clinical picture
A-Symptoms : Asymptomatic → 40% of cases .
Pruritis vulvae → 60% of cases .
B-Signs : =N/E
Site : Usually non-hair bearing surface of the vulva → labia minora
→ fourchette
Shape : sharply demarcated pigmented lesions : erythematous , black , brown or white .
+ aceto-white after addition of acetic acid .
Special investigations   =screening of cancer vulva .
1-Scraping
2-Toulidine blue test with colposic guided biobsy :
Technique : → paint the cervix with toulidine blue 1% .
→ leave the stain for 3 minutes .
→ wash the vulva by 3% acetic acid
if removed blue colour → normal .
if retained blue colour → ↑ nuclear activity (malignancy or infection) .
→ colposcopic guided biopsy from blue areas .
Treatment
A-Prophylactic : as cancer vulva.
B-Curative : A-Ablative procedures : failure rate 10-20%
→ LASER ablation.
→ in VIN 1 , VIN 2 & focal VIN 3 .
B-Excitional procedures :failure rate 15-25%
→ Wide local excision or vulvectomy(simple or skinning)
→ in multifocal VIN 3 or suspicion of malignancy .

-Follow up : Every 3-6 months for the first year.
Every 6 months during 2
nd
& 3
rd
year .
Then every year for 5 years .
 
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Cancer vulva
Incidence
-3-4 % of all gynecological malignancies (4
th
common malignancy of female genital tract).
High risk factors (predisposing factors)
1-Age : 60 -70 Y. (there is another peak in younger patients in association with HPV infection)
2-Parity : no effect .
3-Socioeconomic status : low (bad hygine).
4-Chronic irritation & pruritis :
-Lack of cleanliness & improper vulval skin aeration .
-Infection with pruritis e.g, monilial vulvo-vaginitis (esp. DM) .
-Chemical : deodorants , perfumed soaps , sprays , synthetic underwears , mineral oils
& arsenical substances .
5-STDs : HPV (The most important) , HSV type II , HIV , syphilis , condyloma accuminata ,
lymphgranuloma venerium , lymphgranuloma inguinale .
6-Precancerous lesions : → VIN
→ Vulval dystrophy : hypertrophic with atypia
Lichen sclerosus
Sites
1- Inner sides of both labia minora
2- May arise from the Clitoris
Pathologic features
N/E
1-Malignant ulcer : → raised everted edges , indurated hard base , necrotic floor with areas of hage & necrosis .
2-Malignant nodule → that forms un ulcer later .
3-Cauliflower mass
4-Malignant melanoma
5-Rodent ulcer .
M/E
1-Squemous cell carcinoma : 90 %
2-Adenocarcinoma : from sweat glands & Bartholin's gland.
3-Malignant melanoma.
4-Basal cell carcinoma.
Spread
1-Local spread : to → vulval skin and supporting soft tissue , may be kissing ulcer .
→ Vagina , urethra, anus.
→ Pubic bones, bladder base , rectum.
2-Lymphatic spread : (early)
-To superficial inguinal LNs → deep inguinal LNs → femoral & external iliac LNs
-Clitoris → gland of Cloquet (deep femoral LNs) .
3-Blood spread : (very late & rare) → To lung , liver , bone , brain .
 
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FIGO staging
1-TNM staging :
T (Tumor size) : → T
1
: <2cm, confined to the vulva.
→ T
2
: >2cm, confined to the vulva.
→ T
3
: Any size, local spread (urethra, vagina, perineum and anus).
→ T
4
: Any size, spread to bladder, rectal mucosa or fixed to bone.
N (Lymph node) : → N
0
: No palpable regional lymph node.
→ N
1
: Unilateral regional lymph node metastases.
→ N
2
: Bilateral regional lymph node metastases.
M (Metastasis) : → M
0
: No metastases.
→ M
1
: Distant metastases, including pelvic nodes.
2-Surgical staging :
Stage 0: Carcinoma in situ
Stage 1: (T
1
N
0
M
0
).
-Tumor <2cm, confined to the vulva + No clinically suspicious nodes + no metastasis.
Stage 2 : (T
2
N
0
M
0
).
-Tumor >2cm, confined to the vulva + No clinically suspicious nodes + no metastasis.
Stage3:(T
1
,
2
,
3
N
1
M
0
).
-Tumor of any size or adjacent spread to the vagina, anus or distal urethra + clinically
suspicious unilateral LNs + no metastasis.
Stage 4:
4A → (T
4
N
0,1

,2
, M
o
) : Any size, spread to bladder, rectal mucosa or fixed to bone.
→ (T
1

,2
,
3
N
2
M
o
) : clinically suspicious bilateral regional LNs metastases.
4B → (any T any N M
1
) : distant metastasis .
Diagnosis
A-Symptoms :
1-Long standing pruritis vulvae : (most common)
2-Others :
-Asymptomatic : early in the disease .
-Mass arising from vulva .
-Bleeding : mild postmenopausal bleeding .
-Vaginal discharge :Serous , then serosangenous then offensive vaginal discharge
-Pain .
-Cachexia .
B-Signs :
A-General examination :
-Cachexia. -Inguinal lymph nodes may be palpable.
B-Abdominal examination :
C-Local examination 1.-Vulva =N/E : → 1-Malignant ulcer : → raised everted edges , indurated hard base
,necroticfloor with areas of hage & necrosis .
2-Malignant nodule → that forms un ulcer later .
3-Cauliflower mass
4-Malignant melanoma
5-Rodent ulcer
6-kissing ulcer .
2-Background vulval dystrophy or VIN .
3-The vagina urethra & anus : careful examination.
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Pre- Operative investigations
1-Vulval biopsy : → Wedge biopsy → Edge biopsy
2-Investigations to detect metastasis :
3-Preoperative investigations :
-CBC
-Liver
Kidney
ECG
B

Treatment of stage I, II, III & IV
Main line of treatment is surgery

I= (T1) : local excision with safety margin with no groin dissection .

II= (T2) : Central large lesions → modified radical vulvectomy +bilateral groin dissection .
Lateralized lesions → modified radical hemi-vulvectomy + ipsilateral or bilateral
groin dissection .

III & IVa = (N1,N2) : modified radical vulvectomy + bilateral groin dissection .
(+external radiation to the pelvis if > 2 +ve LNs)

IVb= (T3,T4,M1) : surgery , radiotherapy (for LNs) , chemotherapy (for metastasis)

Vulvectomy
Types , Components & Indications
1-Radical vulvectomy : (Bassett's operation)
-Technique (Components) : butterfly incision → remove whole vulva with wide safety margin +
bilateral groin dissection + mons veneris + anterior part of perineum
-Indications : no place nowadays.
N.B : Groin dissection : inguinal & femoral lymphadenectomy.

2-Modified radical vulvectomy:
-Technique (Components) : 3 incisions technique : → 1 vulval incision : for vulvectomy .
→ 2 groin incisions : for groin dissection .
-Indications : the routine operation nowadays .


52. Vaginal swellings: M.C.Q
 
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53. Cervical intraepithelial neoplasia (CIN): age incidence, grades, fate (course), diagnosis
(symptoms, VIA test ,colposcopy, bunch → ﺔﻴﺋﻼﻣا ﺔﻄﻠﻏ Punch and cone biopsy), surgical
treatment .(account).
Age
around 35 years
incidence
-The exact incidence is unknown : → asymptomatic → doesn't enter in cancer statistics .
-Estimated to be 100/100000
Grades
-Mild dysplasia (CIN I) 
- affection of deeper 1/3
-Moderate dysplasia (CIN II)
- affection of deeper 2/3
-Severe dysplasia (CIN III)
- affection of nearly whole thickness with no basement membrane invasion .
Fate (course)
-30% of CIN will progress to invasive cervical carcinoma within 10-15 years .
Diagnosis
Symptoms
-Asymptomatic → majority of cases .
-May be contact bleeding , vaginal discharge .
Via test
(visual inspection with acetic acid)
Technique : painting the cervix with acetic acid .
Results : → pink in colour Benign cells : (normal).
→ white (aceto-white areas) → Cells with abnormal DNA content →procede to
either Schiller's iodine or colposcopy.
Advantages : alternative to Pap smear in developing countries with good results.
 
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Colposcopy
(low power magnification of the cevix : 6-40 times)
Technique :
A-Without acetic acid : by green filter to see pattern of blood vessels
Punctation & mosaicism → CIN
Looped , branching or corkscrew (J -shaped) → cancver cervix
B-With acetic acid : 3-5 % acetic acid for 1-2 minutes .
Pink → normal .
Acetowhite → satisfactory :all transformation zone & the lesion are visualized
→ unsatisfactory : not all transformation zone & lesion are visualized
→ colposcopic guided biopsy + endocervical curettage
Advantages : diagnostic (best biopsy) & detect site of lesion.
Disadvantages : shows only ectocervix Not useful in gross lesions
N.B : -Criteria to exclude invasive carcinoma by colposcope :
→ transformation zone fully visible .
→ lesion seen in its entirety
→ Endocervical curettage is –ve for dysplasia
→ no discrepancy ( ) pap smear & biopsy .
→ No suspicion of invasion on Pap , colposcopy or biopsy .
Cervical punch biopsy see 1
st
figure →
- Small tissue samples (Punch) are taken from the cervix
and examined.
- The cervix may be stained with iodine solution in order
to see abnormalities better.

Cone biopsy see 2
nd
figure →
- This is a minor operation that usually done under general anaesthetic.
- A large area (as a Cone) of tissue around the cervix is excised for path.
examination.
- The cone includes the whole area of the cervical canal (the inner lining
of the cervix ) where there might be abnormal cells.

Surgical treatment
Excitional procedures :failure rate 2-5%
1-LEEP (loop electrosurgical excision procedure)
2-LASER conization
3-Cold knife cone biopsy

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54. Cancer cervix: age incidence, high risk factors ( Predisposing factors), sites, pathologic
features (N/E+M/E) , spread, diagnosis ( symptoms, signs , special investigations). FIGO
staging, prophylactic III, treatment of sage I , II ,III & IV.Prognosis. Wertimes ﺔﻴﺋﻼﻣا ﺔﻄﻠﻏ
→ Wertheim's operation : indication ,principle:parts being removed.(account).
Age
45 -60 Y
Incidence
**Cancer cervix is the 2
nd
most common female cancer (after breast cancer) worldwide
** General incidence : 10-13 /100000
**In many developing countries : It is the most common gynecologic cancer.
In the developed countries : the 2
nd
common after endometrial carcinoma .
-The decrease in the incidence of cancer cervix in developed countries, is due to:

1. Early and increased rate of diagnosis of precancerous lesions of cancer cervix.
2. Low parity +prolonged life expectancy & post menopausal ERT.
3. Early and increased rate of diagnosis of endometrial carcinoma.

High risk factors ( Predisposing factors)
1-Age : 45 -60 Y.
2-Parity : multipara .
3-Socioeconomic status : low (high parity + early marriage)
4-Race : ↑ in black & Christians , ↓ in J ewesses & Moslems (circumcision of males) .
5-Sexual activity & STDs :
-The most important risk factor → cancer cervix is disease of prostitutes
(almost unknown in virgins & nuns )
-Sexual activity : predisposing factors : → Early age of sexual activity (Adolescents).
→ Early age at the 1
st
pregnancy.
→ Multiple sexual partners and prostitution.
Mechanism : → smegma is oncogenic .
→ introduction of oncogenic viruses by STDs.
→ semen act as mutagen with abnormal growth of cx. epith.

-STDs :-Human papilloma virus (HPV) → The most important risk factor
→ HPV type 16 , 18 arefound in 90% of cases of high gradeCIN & cancer cervix .
-HSV type II
-HIV

6- Smoking: byproducts of cigarettes smoke are concentrated in cervical mucous
→ depletion of macrophage Langerhan's cells .
7-Precancerous lesions : CIN (risk of malignancy ﺐﺘﻜﻳ)

Sites
a) Ectocervical carcinoma: (80%)
b) Endocervical carcinoma : (20%)
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Pathologic features
N/E
a-Ectocervical carcinoma: (80%)from squemous epith. covering portiovaginalis . Maybe :
1-Exophytic : (cauliflower mass)
→ Large , friable fungating mass , projecting into vagina with necrotic surface &
areas of hemorrhage & necrosis .
2-Endophytic : Malignant ulcer : → raised everted edges , indurated hard base ,
necrotic floor with areas of hage & necrosis .
Malignant nodule → that forms un ulcer later .

b-Endocervical carcinoma : (20%) from columnar epithelium of cervical canal .
Endophytic : → barrel shaped cervix .
M/E :
1-Squemous cell carcinoma : (80-90 %)
→ All ectocervical + 50% of endocervical carcinoma .
2-Adenocarcinoma. (10-20 %) clear cell carcinoma most likely to develop in
foetuses exposed to DES in utero .
3-Adenosquamous carcinoma.
4-Sarcoma & Malignant melanoma: rare.

**Histopathologic Grading : It depends on degree of differentiation
1-Wentz & Reagan classification :
-Large cell non keratinizing : best prognosis → most radiosensitive .
-Large cell keratinizing : intermediate prognosis .
-Small cell non keratinizing : worst prognosis .

2-Martisloff classification :
-Spinal cell tumor : large cells → best prognosis .
-Transitional cell tumor : intermediate prognosis .
-Spindle cell tumor: small cells → worst prognosis .

3-Broader's grading : see endometrial carcinoma
Spread
1-Local spread : -Outwards → cervical stroma . –Laterally → parametrium .
-Upwards → body of the uterus . -Downwards → vagina .
-Anteriorly → urinary bladder -Posteriorly → rectum
2-Lymphatic spread : (early)
-Through lymphatics of cervix (anatomy ﻦﻣ ﺐﺘﻜﺗ)
-Main LNs are external iliac LNs , then to common iliac LNs .
3-Blood spread : (very late & rare) → To lung , liver , bone , brain .
4-Peritoneal implantation .
 
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Diagnosis
Symptoms
1-Bleeding : (Most common symptom)
-Contact bleeding : following intercourse , douching & PV → 1
st
symptom.
-Perimenopausal metrorrhagia .
-postmenopausal bleeding .
2-Vaginal discharge :
-Serous , then serosangenous then offensive vaginal discharge (infection & necrosis).
3-Pain :
-Backache : infiltration of uteroscocal ligaments .
-Suprapubic pain: in pyometra.
-Ureteric colic : infiltration of ureter .
-Dysuria : infiltration of bladder .
-Dyschazia : infiltration of rectum:.
4-Cachexia : & signs of metastasis .
5-Others :
-Asymptomatic : early in the disease .
-Pelvic pressure symptoms : Urinary → frequent micturition , retention.
Rectal → dyschazia (pressure on pelvic colon)
-Abdominal enlargement : only in pyometra .
Signs :
A-General examination :
-Signs of renal failure.
-Cachexia.
-Inguinal lymph nodes may be palpable.
B-Abdominal examination :
-In advanced cases there may be: ascites , palpable omental or hepatic metastases.
-The uterus is palpable abdominally only in pyometra .

C-Local examination
1.-Cervix : → cauliflower mass : N/E ﺐﺘﻜﺗ + bleeds on touch .
→ malignant ulcer : N/E ﺐﺘﻜﺗ + bleeds on touch .
→ barrel shaped cervix .
2-Sounding : → very easy (Krobac's sign) .
→ friable necrotic tissues → easy passage of the sound → bleeding .
3-The vagina : careful examination.
4-Bimanual examination : → The uterus for size and mobility.
→ Adnexae for masses.
5-PR : for parametric infiltration .

 
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Special investigations
A-Screening : (early detection) (diagnosis of CIN) ٤٤ ﻖﺑﺎﺴﻟا لاﺆﺴﻟا ﻲﻓ ﺔﺑﺎﺟﻹا
B-Investigations for established cases :
1-Cervical biopsy : Types are :
→ colposcopic guided biopsy (ther best) → conization
→ multiple punch biopsy → 4 quadrant biopsy
→ ring biopsy → wedge biopsy
→ endocervical curettage : for endocervical carcinoma (part of fractional D & C)
2-Colposcopy of micoinvasive carcinoma :
a. Abnormal blood vessels .
b. Irregular surface contour .
c. color tone changes.
d.Atypical transformation zone : acetowhite , punctuation , mosaicism .
3-Investigations to detect metastasis :
→ Brain CT → Bone survey
→ Chest X-ray → abdominal US
→ colonoscopy → IVP
→ Cystoscopy : findings are :
1-Elevation of the bladder base .
2-Bollus edema of the bladder base . Pressure effects
3-Furrows & ridges on the bladder base .
4-Beeded blood vessels
5-Infiltration & ulceration .
6-Fistula formation . stage IV a
4-Preoperative investigations :
e.g, CBC , liver function tests , kidney function tests , ECG , …etc .

FIGO staging
Stage 0: Carcinoma in situ
Stage I : [confined to cervix (extension to the corpus should be disregarded)].
-Stage Ia : microinvasive carcinoma , depth of invasion <5 x 7 mm .
Ia1 → depth of invasion is <3 mm x <7 mm .
Ia2 → depth of invasion is 3-5 mm x <7 mm .
-Stage Ib : macroinvasive carcinoma , depth of invasion >5 x 7 mm .
Ib1 → Lesion is < 4 cm .
Ib2 → Lesion is > 4 cm .
Stage II: (extension beyond cx but not reaching lower 1/3 vagina or lat. pelvic wall)
-Stage IIa : involvement of vagina not reaching lower 1/3 + no parametric infiltration.
-Stage IIb : parametric infiltration but not reaching lateral pelvic wall .

Stage III: (carcinoma reaching lower 1/3 vagina and/or lat. pelvic wall)
-Stage IIIa : involvement of lower 1/3 vagina + not reaching lateral pelvic wall .
-Stage IIIb : parametric infiltration reaching lateral pelvic wall.
and/or : hydronephrosis or non functioning kidney .
[[
Stage IV: (involvement of bladder or rectum or extension beyond true pelvis)
-Stage IVa : tumor invasion of bladder or rectum mucosa.
-Stage IVb : distant metastases .
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Prophylactic ttt
-Screening programs for CIN
-Proper TTT & follow up of CIN
-Prevention & TTT of predisposing factors e.g, change sexual behaviour , stop smoking ,…etc

Treatment of sage I , II ,III & IV
Main line of treatment is radiotherapy
Scheme for TTT :
Stage I : Ia1 Conization Wertheim's operation Radiotherapy
Ia2 Radical trechelectomy Or Wertheim's operation Or Radiotherapy
Ib Radical trechelectomy Wertheim's operation Radiotherapy
Stage II : IIa Wertheim's operation Radiotherapy
IIb Radiotherapy
Stage III : Radiotherapy
Stage IV : Pelvic exentration + postoperative radiotherapy Or Radiotherapy

Prognosis
It is stage dependent
•Stage 1 : surgery and radiotherapy are equally effective (90-95% 5 year survival).
•Stage 2 : 65-70% 5Y S.
•Stage 3 : 20-25% 5Y S.
•Stage4 : < 5% 5Y S.
**Prognostic factors : prognosis is bad when :
1-Young age .
2-late diagnosis.
3-Early lymphatic spread .
4-Severe bleeding & cachexia.
5-Bladder spread .
6-Renal failure .

Wertheim's hysterectomy operation (Radical hysterectomy)
Indication
stages I – IIa .
Principle
TAH +BSO +remove upper cuff of vagina + pelvic lymphadenectomy
Parts being removed
 Uterus (Womb)
 All the tissues holding womb in place
 The top of i vagina
 All the lymph nodes around the womb
 
 
Wertheim's spelling يﻮﻔﺸﻟا ﻲﻓ مﺎه




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55. Fibroids: incidence, high risk factors ( predisposing factors), sites & types, pathologic
factures( N/E/M/E), effect of fibroid on pelvic organs, secondary changes in fibroids,
symptoms , signs , DD, special investigations, treatment. Myomectomy: definition,
indications, contra indications, types &approaches .(account).
Incidence
-It is the commonest uterine tumor & commonest benign tumor of the female genital tract.
-It affects 20% of women above 30 years.

High risk factors ( predisposing factors),
1-Age : >30 years . (especially 30 -40y)
2-Parity : nullipara or low parity (hyperestrogenic state).
3-Socioeconomic status : high (low parity & use of ERT)
4-Race : negroes .
5-Familial predisposition : +ve .
6-Hyper-estrogenic state : evidences are :
1. It is common in nullipara & women of low parity.
2. It does not appear before puberty and never arises de novo after menopause.
3. It increases in size in pregnancy & regresses after labor & shrunk after menopause.
4. It contains estrogen receptors & is produced by estrogen in expremental animals .

Sites & types



Uterine (99%) Extra uterine
(1%)


Corporeal (95%) Cervical (4%)



Interstitial(60%) Submucous(15%) Sub serous (20%)
-All start interstitial -Projects into cavity -Projects outwards
-Covered by endometrium -Covered by peritoneum
-If pedunculated → -If pedunculated →
submucous fibroid polyp subserous fibroid polyp -Broad ligament
(if detached from ut. & →true →pseudo
attached to nearby organ -Round ligament
& takes its bl. supply -Ovarian ligament
→ parasitic fibroid) -Utero-sacral ligaments

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Pathologic features
N/E
Sites: see above
Number: → Corporeal fibroids are usually multiple.
→ Cervical fibroid is usually single.
Size: → Thesize varies from a small seedling to a large tumor.
Consistency : → firm in consistency.
→ becomes soft during pregnancy or with hyaline degeneration.
→ becomes hard with calcification.
Cut section: → shows a whorly appearance & is paler than the surrounding.
→ has a false capsule formed of compressed surrounding myometrial muscles.
Bl. supply: →Supplied by the vessels in the capsule that passes inwards to the tumor,
So : degeneration starts in center & calcification occurs at the periphery.
→Fibroid polypi obtain their blood vessels from the pedicle,
So : necrosis starts at the tip.
M/E
Smooth muscles → Short thick nuclei & stains yellow with Van Gieson stain.
Fibroblasts → Fusiform nuclei & stains pink with Van Gieson stain.
Secondary changes in fibroids
1-Infection :
Causes : → In a submucous fibroid after labor or abortion.
→ At the necrosed tip of a submucous fibroid polyp.
→ In a subserous fibroid from a nearby infected organ e.g. appendix.
Clinical picture: → Lower abdominal pain & tenderness.
→ Fever & tachycardia.
Treatment: → Antibiotics.
→ Myomectomy or hysterectomy after control of fever.
2-Necrosis: Occurs at the tip of a submucus fibroid polyp.
3-Degeneration :
A-Post menopausal Atrophy.
B-Hyaline degeneration: "The commonest degeneration"
-It starts in the center as the center is the least vascular → the whorly appearance
is lost & is replaced by a hyaline material → the tumor becomes softer.
-Symptoms: Dull aching pain.
C-Cystic degeneration:
-The tumor becomes cystic .
-It is due to → liquefaction of the hyaline material "false cyst" or
→ telangiectasis "true cyst''
D-Fatty degeneration:
-The tumor becomes yellow & softer.
-It precedes calcification.
E-Calcification:
-The tumor becomes hard.
-White patches are seen at the periphery i.e. along the blood vessels.
-X- ray reveals an egg shell appearance or a womb stone.
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F-Red degeneration : (Necrobiosis) (Corneous degeneration )
-Incidence: common in preg. , due to: → Rapid growth of the tumor
→ Kinking of blood vessels of the capsule.
→ Increased fibrinogen during pregnancy.
-Pathogenesis: Thrombosis in vessels of capsule → ischemia → a lipoid toxin →
intravascular hemolysis→ Hb diffuses out & stains tumor red.
-Pathology : Fresh tumor is red , has a fishy odor & darkens on exposure to air.
-Clinical picture : → Acute abdominal pain & tenderness. → Vomiting.
→ Low-grade fever & tachycardia.
-Differential diagnosis : → Acute pyelitis
→ Concealed accidental hemorrhage.
-Treatment: During pregnancy: → Myomectomy should be avoided to avoid bleeding.
→ Treatment is conservative i.e. rest & analgesics.
→ Myomectomy is only done if pain persists.
In non-pregnant (rare): Control of pain then surgical treatment.
4-Vascular changes:
-Congestion due to torsion of a pedunculated fibroid.
-Edema due to torsion or infection.
-Lymphangiectasis or telangiectasis.

5-Malignant Changes : (Leiomyosarcoma)
-Incidence: is very rare (<0.1% of myomas).
-C/P: → Rapid growth.
→ Rapid recurrence after removal.
→ Postmenopausal growth.
→ Postmenopausal bleeding & pain.
-Pathology: At the operation, sarcoma is suspected by:
→ Infiltration of the capsule.
→ Loss of the whorly appearance.

Effect of fibroid on pelvic organs
1-Uterus: a. enlargement → Asymmetrical : with multiple fibroids.
→ Symmetrical: in submucous or single fundal interstitial myoma.
b. Increased vascularity.
c. Endometrial hyperplasia.
d. Increased surface area of the endometrium.
e. Myometrial hypertrophy.
2-The ovaries: Functional follicular cysts are commonly associated with fibroid.
3-The tubes : → Chronic salpingitis (20%).
→ Tubal block by cornual fibroid.
→ Stretch of the tube due to large broad ligament fibroid.
4-The urinary bladder : Anterior wall subserous myoma causes frequency of micturition.
5-The urethra :Stretch by large interstitial cervical fibroid causes retention of urine.
6-The ureter: Large broad ligament or cervical myoma causes hydroureter & hydronephrosis.

 
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Symptoms
1-Asymptomatic :
-50% of cases → most common presentation & discovered accidentally
-Usually with small subserous myomas .

2-Bleeding : (Most common symptom of fibroid if symptomatic)
-Any type of abnormal uterine bleeding can occur but menorrhagia is the most common .
**Menorrhagia (The commonest) (Not present in subserous or cervical fibroids) due to :
1. Increased vascularity of the uterus.
2. Increased surface area of the endometrium.
3. Fibroid interferes mechanically with uterine contractions.
4. Associated endometrial hyperplasia .
**Metrorrhagia : occurs only in
1. Complicated fibroid e.g, Ulcerated tip of submucous fibroid polyp , inf. & deg.
2. Associated endometrial hyperplasia .
3. Associated malignancy or malignant changes
**Postmenopausal bleeding: → Malignant change (leiomyosarcoma).
→ An associated lesion as endometrial cancer.
**Polymenorrhea due to : ovarian congestion as a result of pelvic congestion.

3-Vaginal discharge : White (leukorrhea) → pelvic congestion.
Yellowish offensive → infection & malignancy .

4-Gradual abdominal enlargment:
-Only in huge fibroids (the only symptom in large subserous fibroid)

5-Pain:
1-Dull aching pain → hyaline degeneration. → pelvic congestion
→ Malignant transformation
2-Acute abdomen → red degeneration . → internal hemorrhage
→Torsion of pedunculated subserous myoma
3-Colicky pain → uterine contractions to expel a polyp
4-Pain with purulent discharge & fever → infection .
5-Pain due to pelvic pressure symptoms e.g, dysuria & dyschazia .

6-Pressure symptoms:
a-Abdominal pressure symptoms : (in large subserous fibroid)
-Dyspnea & palpitation → pressure on the diaphragm
-Dyspepsia → pressure on stomach & intestine
b-Pelvic pressure symptoms : (in cervical & impacted fibroid)
-Urinary → frequent micturition , retention hydroureter & hydronephrosis.
-Rectal → dyschazia (pressure on pelvic colon)
7-Symptoms of pelvic congestion:
-Congestive dysmenorrhea, menorrhagia , dysparunia & leucorrhea.
8- Infertility : due to :
1. Vagina : dyspareunia .
2. Cervix : Cervical fibroid causing distortion of the cervical canal.
3. Uterus : → Submucous fibroid interfering with implantation.
→ congested & hyperplastic endometrium not suitable for implantation
4. Ovary : Associated anovulation.
5. Tubes : tubal obstruction by corneal fibroid + associated salpingitis.

Fibroid is a cause of infertility after exclusion of all other causes.
[
9-Symptoms during pregnancy : see later (ﺐﺘﻜﺗ).

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Signs :
General exam.: → Pallor due to anemia → rarely, facial flushing due to polycythemia.
Abdominal examination :
-Pedunculated large subserous fibroid → pure abdominal swelling .
-All other types → if large : pelvi-abdominal swelling
1. The lower border can be felt abdominally.
2. The surface is irregular bossy or smooth.
3. The consistency is firm. It is soft with pregnancy & hyaline degeneration.
4. Mobile from side to side but not up & down.
5. Dull on percussion.
6. Auscultation → uterine souffle due to ↑ vascularity
Local examination.
1. The uterus → symmetrically enlarged with submucous fibroid .
→ asymmetrically enlarged with subserous fibroid .
2. Palpation: a fibroid polyp can be felt.
3. The tumor is mobile & its movement is transmitted to the cervix.
Differential diagnosis :
1-Huge fibroid : from other causes of diffuse enlargement of the abdomen.
2-Moderate fibroid : from other causes of pelvi-abdominal swellings.
3-Small fibroid : from other causes of symmetrically enlarged uterus.
4-Fibroid polyp : from other causes of uterine polypi .

Special investigations
1-US : no. , site , size of fibroids .
2-Sonohystrography .
3-HSG : → tubal patency → uterine cavity
4-IVP: especially needed in cases of cervical or broad ligament fibroid.)
5-Endometrial curettage: To exclude malignancy (if metrorrhagia).
6-Plain X-ray .
7-Laparoscopy: To differentiate subserous polyp & an ovarian swelling.
8-Hysteroscopy: To detect submucous myoma.
9-Preoperative investigations e.g. CBC, kidney function tests, …etc .


Treatment
**Factors affecting treatment:
1-Age 2-Parity. 3-Severity of symptoms.
4-No., size & site of the myomas. 5-Associated pregnancy. 6-Associated malignancy.

**Lines of TTT :
Main line of treatment is surgery

I-No treatment: (with follow-up every 6 months)

No symptoms = no treatment except :

1. Large myoma > 12 weeks : as it is liable to degeneration.
2. Rapidly growing myoma : due to suspicion of malignancy.
3. Pedunculated subserous myoma : as it is liable to torsion.
4. Submucous myoma in a nullipara : to avoid infertility or abortion.
5. Large interstitial cervical fibroid : to avoid ureteric compression.

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II-Medical & Symptomatic Treatment
-GnRH analogues : → Patients near menopause + small myoma & slight menorrhagia.
→ If the patient is unfit for surgery
→ In the preoperative period to shrink the myoma.
-Gestogens :could be used instead of GnRh analogues
III-Management during pregnancy : see later .

IV-Surgical Treatment : I. Myomectomy. 2.Hysterectomy.

Myomectomy
Definition
Surgical removal of the myoma with preservation of a healthy functioning uterus .
Indication
→ Young patients (<40 years) desiring pregnancy
contra indications
1-Patients above the age 40 years.
2-Large number of fibroids so that after myomectomy a useless uterus is left.
3-Suspicion of malignancy.
4-Cervical fibroid .
Types and Routes (approaches):
A. Abdominal :
1-Incision: → Pfannenstiel's incision or midline sub-umbilical if the myoma is large.
2-Temporary hemostasis:
1-Temporary occlusion of uterine arteries at the level of the internal os by:
-Rubber tourniquet(less traumatic) -Bonney's myomectomy clamp(more traumatic)
2-Myometrial injection of pitressin.
3-Preoperative rectal misoprostol.
3-The uterine incision , should be:
→ Vertical. → Midline. → In the anterior wall of the uterus.
→ Allows removal of the maximum number of myomas by a tunneling techniques.
4-Removal of the myomas : followed by obliteration of the tumor bed.
-If pedunculated subserous myoma: The pedicle doubly clamped, cut & ligated.
-If broad ligament myoma: The round ligament is cut & ligated first.
-Posterior wall myoma : is removed by:
1. Bonney's Hood operation: Transverse fundal incision to enucleate the
myoma then flap is pulled forward & sutured anteriorly.
2. Transcavitary incision.
3. Posterior wall incision (better avoided as it causes adhesions).
B. Vaginal : For a fibroid in the portio-vaginalis of the cervix:
1. Polypectomy : for a small cervical fibroid polyp.
2. Morcellation : (piece meal removal) for a large cervical fibroid polyp.
3. Enculeation : for an interstitial fibroid in the portio-vaginalis.
C. Laparoscopic myomectomy : For small subserous fibroid (<5 cm size).
D. Hysteroscopic myomectomy: For small submucous fibroid.


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56. Endometriosis: definition, high risk factors (predisposing factors) ,sites, diagnosis
(symptoms, signs , DD special investigations), treatment ( no ttt ???, medical, hormonal ,
surgical ttt).(account)
Definition
-The presence of endometrial tissue (glands and stroma) outside the normal uterine cavity.
-Adenomyosis → the presence of ectopic endometrium inside the myometrium.
→ no longer considered as endometriosis interna → discussed separately .
High risk factors (predisposing factors)
-As fibroid ﻖﺑﺎﺴﻟا لاﺆﺴﻟا ﻦﻣ (ﺐﺘﻜﺗ) + → manipulation of female genital tract during menses e.g, HSG , PV
→ cryptomenorrhea
Sites

Pelvic Extra pelvic


Genital Extra genital


Ovaries (65%) Douglas pouch Scar of previous laparatomy
Tubes Pelvic peritoneum Umblicus
Vagina Urinary bladder Lung
Vulva Rectum Intestine
(scar of prev .episiotomy) Uterine lig. Nose
Uterosacral ligament
Most common sites : → Ovary → Douglas pouch
→ Tubes → Uterine ligaments & uterosacral ligaments
Diagnosis
-Endometriosis is a surgical diagnosis following laparatomy or laparoscopy.
-Suspected clinically by triad of endometriosis→ Infertility
→ Deep dysparuenia
→ Crescendo dysmenorrhea
Symptoms
1- Infertility : in 30-40% of cases of endometriosis , due to :
1-Vagina : dyspareunia .
2-Uterus : congested & hyperplastic endometrium not suitable for implantation
3-Ovary : Associated anovulation.
4-Tubes : peritubal adhesions + associated salpingitis.
5- Pelvic Peritoneum : marked adhesions → interfere with normal tubo-ovarian relationship.
6-Immunological : ↑ macrophage & complement activity → sperm engulfing .
7-↑ PGs & hyperprolactinemia .

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2-Deep dysparuenia: due to :
a-Cul-de-Sac endometriosis.
b-Endometriosis of the rectovaginal septum.
c-Ovarian endometrioma.
d-Fixed RVF.
3-Crescendo dysmenorrhea
-2 days before menstrual flow : start dull aching pain that ↑ gradually.
-With maximum flow : maximum intensity of the pain & then ↓ gradually .
-2 days after cessation of menstruation : cessation of pain .
**Other symptoms :
1-Asymptomatic :
2-Bleeding : in the form of Menorrhagia , due to :
1. Increased vascularity of the uterus.
2. Increased surface area of the endometrium.
3. Associated endometrial hyperplasia .
(in bladder endometriosis → cyclic hematuria)
3-Vaginal discharge : White (leukorrhea) → pelvic congestion.
4-Pain: deep dysparuenia & crescendo dysmenorrhea +
-Chronic pelvic pain : 25% of cases of chronic pelvic pain have endometriosis .Due to :
→ Sequential swelling and extravasation of blood in the surrounding tissue.
→ scarring and retraction of the peritoneum.
→ ↑ levels of PGs and histamine (so , anti-PGs are used for symptomatic TTT) .
- Acute abdomen → ectopic pregnancy . → rupture endometriotic cyst
-Dysuria & dyschazia : bladder endometriosis & GIT affection .
Signs
-Signs are non specific but suggestive , the most common are :
1. Nodular thickening and tenderness of the uterosacral ligaments and Cul-de-sac.
2. Retroverted fixed uterus.
3. Fixed tender adenexal masses.
Special investigations
1-Laparascopy : surest method of diagnosis , it shows :
1-The classical endometriotic implant is characterized as brown or black
pigmentation (powder-burn lesion) .
2-Hemorrhagic or flame shaped lesions.
3-Filmy or fibrotic adhesions.
4-Chocolate cysts of the ovary.
5-Atypical or subtle lesions : → Clear vesicular, white opacified lesions.
→ Polyploid or red hemorrhagic vesicles.
→ Peritoneal retraction and surface defects.
2-US : TVS → chocolate cysts .
→ nodules in Douglas pouch .
3-Biopsy : From lesions in umbilicus & previous scar → endometrial glands & stroma .
4-Cystoscopy & colonoscopy .
5-Serum CA 125 : (non specific)
 
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DD
1-From other causes of nodules in Douglas pouch .
2-From other causes of ovarian swellings .
3-From other causes of dysparuenia
4-From other causes of chronic pelvic pain .
5-From chronic PID .

Treatment
**Factors affecting treatment :
1-Age 2-Parity.
3-Severity of symptoms. 4-Staging.
**Lines of TTT :

Main line of treatment is hormonal TTT

(Expectant treatment )
**Indications : Young women with pelvic pain when there is no immediate interest in
pregnancy & endometriosis is apparent on laparoscopy.
**It includes : Analgesics (NSAIDs).

Hormonal Treatment :
**Indications : young infertile woman with stage 1 & 2 endometriosis.
It may be combined with surgery.
**Principle :
→ Ectopic endometrium like normal endometrium responds to hormonal regulation.
→The objective of TTT is to cause atrophy of the ectopic endometrium
by pseudopregnancy and pseudomenopause states.
**It includes :
A-Pseudo-pregnancy State: Can be produced by:
(Pseudo-pregnancy state causes decidualization, necrosis & resorption of implants)
1-Combined Oral Contraceptive Pills (COCs) :
Dose : 1-4 tab. /day without rest for at least 6 to 9 months .
Result : It is a cheap method and effective :
→ 50% pain relief → 25-50% preg. rate → But, 40% recurrence rate.
Side effects : see contraception .
2-Gestagens only (Provera or depot medroxy progesterone acetate DMPA):
Dose : → 10 - 30 mg per day provera.
→ 150 mg /3M DMPA for 6 to 9 months.
Disadvantages : → Breakthrough bleeding:
→ Delayed return of fertility.

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B-Pseudomenopause state : can be induced by:
1-GnRH analogues (agonists):
Action : pituitary down regulation & desensitization to endogenous GnRH →
a state of hypogonadotrophic hypogonadism (medical hypophysectomy).
Dose : Goserlin (Zoladex): 3.6 mg SC /month.
Triptolin (Decapeptyl): 3.75 mg IM /month.
Buserlin (superfact): nasal spray 300 to 400 µg/ tds.
Results: → Symptomatic relief in 50% after 6months.
→ Regression of endometriotic lesions in 80% of cases.
→ Recurrence in 25% after stoppage of treatment.
Side effects : → Menopausal symptoms & osteoporosis
→ Initial flare up of endometriotic symptoms in first weeks after
treatment due to flare up before down regulation.

2-Danazol: (oral synthetic 3-isoxazole derivative of 17 α ethinyl testosterone)
Action : suppression of pituitary gonadotrophins + inhibition of
ovarian steroidogenesis (medical oophorectomy).
Dose : 600 to 800 mg/day for at least 6 to 9 months.
Result : the most effective approved drug for the treatment of endometriosis.
Side effects : virilizing symptoms.
Surgical Treatment:
1-Conservative treatment:
Lines : → Adhesiolysis.
→ Surgical excision of endometriomas.
→ Electrocoagulation, cauterization or laser evaporation of implants.
→ Laparoscopic uterosacral nerve ablation (LUNA) to relief pain
(Reconstruction of the peritoneal surface to cover raw areas is
essential to prevent adhesions).
Indications : infertility .

2-Radical treatment:
Line : total abdominal hysterectomy with bilateral salpingoopherectomy + HRT .
Indications : → Recurrent disease.
→ Severe endometriosis.
→ Patient completed her family.
→ No response to medical therapy.

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57. Adenomyosis : definition, high risk factors ,pathology of myometrium, diagnosis (
Symptoms , signs , DD special investigations), treatment .Types of uterine polypi: corporeal
ploypi and cervical polypi ( enumeration ).
Definition
The presence of endometrial glands and stroma in the myometrium .
(usually adjacent smooth muscle hyperplasia → significant uterine enlargement)
High risk factors
-As fibroid ) لاﺆﺴﻟا ﻦﻣ ﺐﺘﻜﺗ ٥٥ ( but in multipara + previous CS , abortions & vigorous curettage .
Pathology of myometrium
N/E: Size of uterus : -Symmetrically enlarged , but usually <10 W (diffuse adenomyosis).
-Asymmetrically enlarged (localized adenomyosis).
Uterine cavity : is enlarged and lined with hyperplastic endometrium.
Cut section: → Small areas of Blood spots within the myometrium.
→ Large cystic space filled with altered blood.
→ Adenomyosis is not capsulated (unlike fibroid).
M/E : endometrial tissue within the myometrium .

Diagnosis
Symptoms
→ Menorrhagia (endometrial hyperplasia).
→ Secondary dysmenorrhea.
→ Pelvic discomfort.
Signs → Uterus is enlarged either symmetrically (<10 weeks) or asymmetrically enlarged.
→ Uterus is tender during bimanual examination.
Special investigations
1-TVS : diffuse echogenicity , myometrial cysts, Subendometrial nodules or linear
striations, poor definition of endometrial-myometrial border .
2-MRI.
3-Myometrial biopsy either hysteroscopic or laparoscopic

Differential diagnosis : from other causes of symmetrically enlarged uterus .

Treatment
A-Medical TTT : NSAIDs , COCs , gestagens , LNG –IUS
B-Surgical TTT : Hysterectomy (without oophorectomy unless indicated)
Endometrial ablation (usually fails)
Types of uterine polypi
A-Cervical B-Corporeal
1-Fibroid polyp 1-Fibroid polyp
2-Mucous polyp 2-Hyperplastic polyp
3-Malignant polyp 3-Malignant polyp
4-Bilharzial polyp 4-Placental polyp
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58. Endometrial hyperplasia : cause, high risk factors ( predisposing factors) pathologic
classification, clinical picture , special investigations ,treatment .(account).
Causes & predisposing factors :
-As endometrial carcinoma but in younger age . مدﺎﻘﻟا لاﺆﺴﻟا ﻦﻣ ﺔﺑﺎﺟﻻا
Pathologic classification
1-Simple Hyperplasia: characterized by:
-An increased glandular to stromal ratio.
-Glands are round or irregular in shape.
-Glands may be dilated or cystic (cystic hyperplasia) and are lined by proliferative type
of endometrial cells.
-The stroma is more densely packed than that of the proliferative endometrium.
-Nuclear atypia is absent.
2- Complex Hyperplasia: (adenomatous)
- ↑ glands crowding with less stroma inbetween (back to back arrangement).
-Glandular architecture is more complex with budding and papillary infoldings.
-Cellular stratification can be present in glands, but preserved polarity of the nuclei.
3-Atypical Hyperplasia:
-Classified as either simple or complex.
-It is characterized by atypia,: a. Loss of polarity.
b. Increased nuclear to cytoplasmic ratio.
c. Large nuclei of various sizes and shapes.
d. Irregularly clumped chromatin.
e. Thickened nuclear membrane.
f. Prominent nucleoli.
Clinical picture :
Symptoms : -Abnormal uterine bleeding (most common)
-Amenorrhea
-Infertility
Signs : uterus may be symmetrically enlarged

Special investigations D & C : characters of curettage → in strips
→ +ve gritty sensation
→ No areas of hemorrhage or necrosis
→ Stop bleeding
Treatment :
A-In childbearing period :
-Without atypia : gestagen therapy for 6 months → if failed → hysterectomy
-With atypia :
patient completed her family → hysterectomy
Patient not completed family → ovulatory drugs & encourage preg. & then hysterectomy .

B-After menopause :
-Without atypia : gestagen therapy for 6 months → if failed → hysterectomy
-With atypia : hysterectomy .
 
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59. Endometrial carcinoma: High risk factors , pre- cancerous lesions, pathologic features
(M/E/N/E), spread. Diagnosis (Symptoms , signs , spcial investigations), FIGO classification
,treatment: prophylactic ttt, Treatment of stage I, II,III and IV . Prognosis .(account).
High risk factors & Pre- cancerous lesions :
1-Age : the median age of diagnosis of endometrial carcinoma is approximately 60years:
3/4 cases → postmenopausal women. 1/4 cases → around menopause.
2-Parity : nullipara or low parity (disease of nulls) .
3-Socioeconomic status : high (low parity + old age & use of ERT )
4-Familial predisposition : or family history of carcinoma of breast, ovary or
colon, Lynch II syndrome (hereditary nonpolyposis colorectal cancer syndrome).
5-Hyper-estrogenic state : (ﺐﺘﻜﺗ). ﻢﻗر لاﺆﺳ ﻦﻣ ٥٥
6-Cancer corpus triad & senile endometritis .
7-Precancerous lesions : endometrial hyperplasia (risk of malignancy ) (Malignant Potential)
1-Simple hyperplasia : Without atypia → 1%
With atypia → 8 %

2-Complex hyperplasia : Without atypia → 3%
With atypia → 24 %
Pathologic features
N/E It maybe : localized : fungating cauliflower or polypoidal mass .
Diffuse : friable cheesy masses allover the endometrium .
M/E
1-Endometrial adenocarcinoma : (80 %)
a-Usual type: endometrioid adenocarcinoma.
b-Variants.
-With squamous differentiation:(adenoacanthoma 15-25 % of cases)
-Villoglandular / papillary (2 % of cases).
-Secretory (1%).
2. Mucinous carcinoma (5 %).
3. Clear cell carcinoma (<5 %).
4. Papillary serous carcinoma.
5. Pure squamous cell carcinoma of the endometrium → rare.
6. Others : undifferentiated carcinoma & mixed carcinoma.
**Histopathologic Grading (Approved by FIGO, 1988.)
-It depends on degree of differentiation i.e degree of similarity ( ) the malignant cells
& the originating mother endometrial cells :
G1 Well differentiated adenocarcinoma
→ <5% of a non-squamous or non-morular solid growth pattern .
G2 Moderately differentiated adenocarcinoma
→ 6-50% of a non-squamous or non morular solid growth pattern .
G3 Poorly differentiated adenocarcinoma
→ >50% of non-squamous or non-morular solid growth pattern
 
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Spread
(It tends to remain limited to the endometrium for a long period)
1-Local spread :
-To myometrium (inner then outer 1/2) → then serosa → then cervix (glands then
stroma) → then in advanced stages : invasion of parametrium, bladder & rectum.
2-Lymphatic spread : (late)
-Through lymphatics of uterus (anatomy ﻦﻣ ﺐﺘﻜﺗ)
-Main LNs are internal iliac LNs then to common iliac LNs.
3-Blood spread : (very late & rare)
-To lung , liver , bone , brain .
4-Seedling :
-To the retro-peritoneal space or vagina after hysterectomy .
Diagnosis
Symptoms
1-Bleeding :
-Most common symptom in the form of postmenopausal bleeding .
(Any postmenopausal bleeding is considered malignant till proved otherwise ,
not because it is the most common but because it is the most serious .)
-If in the perimenopausal period → perimenopausal metrorrhagia .
2-Vaginal discharge :
-Serous , then serosangenous then offensive vaginal discharge (infection & necrosis).
3-Pain : Simpson's pain
-Characteristic for endometrial carcinoma : dull aching pain with intermittent colicky pain .
4-Cachexia : & signs of metastasis .
5-Others :
-Asymptomatic : early in the disease .
-Abdominal enlargement : only in pyometra, associated fibroid .
Signs
A-General examination :
-Obesity.
-Hypertension.
-Cachexia.
-Inguinal lymph nodes may be palpable.
B-Abdominal examination :
-In advanced cases there may be: ascites , palpable omental or hepatic metastases.
-The uterus is palpable abdominally only in pyometra, associated fibroid .
C-Local examination
1.-Uterus : → usually symmetrically enlarged .
→ But may be Normal (slow growth) or smaller ( post menopausal atrophy).
2-Sounding : of the uterus is essential.
3-The suburethral area, the entire vagina and cervix : careful examination. and
4-Bimanual examination : → The uterus for size and mobility.
→ Adnexae for masses.
5-PR : for parametric infiltration .
 
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Special investigations :
A-Screening & early detection :
-Screening programs in endometrial carcinoma have 2 difficulties :
→ not all cases developing breast cancer had definite risk factors .
→ no single test is fully accurate to be clinically reliable .
-High risk group → post menopausal ladies with > 1 risk factors .
-Annual screening is recommended by one of the following :
1-Endometrial cytology : (less accurate)
→ jet washing & aspiration technique ,exofoliative vaginal cytology & vaginal
smear .
2-Office endometrial biopsy without anesthesia : (accuracy nearly as D & C)
3-TVS : endometrial thickness <5 mm → mostly exclude malignancy .
4-Progesterone withdrawal : if +ve in post menopausal women → suspicious .
5-Others : Pap smear , hysroscope , Doppler US .

B-Investigations for established cases :
1-Endometrial biopsy :
-Office endometrial biopsy without anesthesia using Pippelle or Vebra aspirator.
-Fractional D & C : done when
→ office biopsy can't be performed due to cx stenosis or patient discomfort.
→ Women who have persistent symptoms despite of a normal office biopsy.
→ complex hyperplasia with atypia to rule out concomitant invasive
adenocarcinoma
-Hystroscopic guided biopsy : the best .
Criteria of curettage → lesion in clumps not streps
→ endless curettage
→ areas of hemorrhage & necrosis +offensive odour
→ may ↑ bleeding
2-US, sonohystrography , CT and MRI : to assess
a. Endometrial thickness, irregularity and fluid content.
b. Depth of myometrial invasion.
c. Spread outside the uterus.
3-Staging laparatomy : see ovarian cancer .
4-Investigations to detect metastasis :
→ Brain CT → Bone survey → Chest X-ray
→ abdominal US → Cystoscopy & IVP → colonoscopy
5-Preoperative investigations :
e.g, CBC , liver function tests , kidney function tests , ECG , …etc .
 
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FIGO classification
(Surgical Staging) : (FIGO, 1988)
Stage I : (Tumor confined to the uterus)
-Stage Ia : tumor limited to endometrium.
-Stage Ib : invasion of <1/2 of the myometrium.
-Stage Ic : invasion of >1/2 of the myometrium.
Stage II: (involvement of the cervix)
-Stage IIa : involvement of endocervical glands only.
-Stage IIb : cervical stromal invasion.
Stage III: (serosal , vaginal & pelvi-abdominal LN spread)
-Stage IIIa : tumor invades serosa and/or positive peritoneal cytology.
-Stage IIIb : vaginal metastasis.
-Stage IIIc : metastasis to pelvic or para-aortic lymph nodes.
Stage IV: (involvement of bladder or rectum or extension beyond true pelvis)
-Stage IVa : tumor invasion of bladder or bowel mucosa.
-Stage IVb : distant metastases, including intraabdominal or inguinal lymph node.
For all stages except IV b → the degree of differentiation is noted G1, G2, G3
N.B :
- Clinical staging : (FIGO 1977 )
Stage I : (Tumor confined to the uterus) -Stage Ia : uterine cavity <8 cm.
-Stage Ib : uterine cavity >8 cm.
Stage II: (involvement of the cervix)
Stage III: (extends outside uterus but still in pelvis )
Stage IV: (involvement of bladder or rectum or extension beyond true pelvis)
-Stage IVa : tumor invasion of bladder or bowel mucosa.
-Stage IVb : distant metastases, including intraabdominal or inguinal lymph node.


Treatment
Prophylactic ttt
-Screening for endometrial hyperplasia .
-Proper TTT & follow up of endometrial hyperplasia .
-Prevention & TTT of predisposing factors e.g, removal of estrogen secreting tumor ,…etc
Treatment of stage I, II,III and IV
Main line of treatment is surgery

**Surgical Staging Procedure:
1-Total abdominal hysterectomy with bilateral salpingoophrectomy.
2-Peritoneal cytology (washing of pelvis and abdomen).
3-Intraoperative evaluation of the depth of myometrial invasion (by pathologist).
4-Pelvic and para-aortic lymph node sampling is indicated in :
→ Poorly differentiated cancer.
→ Tumor invasion >1/2 uterine wall.
→ Extension of the tumor to the cervix.


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Then after that , according to stage :
Stage Ia G1,2 : No postoperative TTT .
Stage Ia G3 or Ib G1,2 : vaginal cuff irradiation .
Stage Ib G3 , Ic, II, IVa : Pelvic irradiation .
Stage III a : intra-peritoneal installation of P
32

Stage III b , III c : extended field irradiation .
Stage IV b : whole abdomen irradiation , or hormonal therapy , or chemotherapy .
1-Surgery : (the main line of TTT)
1-TAH + BSO :
-The standard operation nowadays
- More radical operations (Wherteim's operation )give no better results & ↑morbidity .
2-Vaginal hystrectomy:
-Indications : with extreme obesity or prolapse .
-Disadvantages : BSO & exploration are difficult .
3-Laparscopic assisted vaginal hysterectomy :
-Still not established .
2-Radiotherapy:
1-Vaginal cuff irradiation : 6000-7000 cGY
-Indications : Stage Ia G3 or Ib G1,2
2-Whole pelvic irradiation:5000-5500 cGY
-Indications : Stage Ib G3 , Ic, II, IVa.
3-Extended field irradiation : 4500-5000 cGY
-Indications : Stage III b , III c
4-Whole abdominal irradiation : 3000 cGY
-Indications : Stage IV b .
5-Intra-peritoneal instlation of P
32
: stage III a
3-Hormonal therapy: Anti-estrogens e.g, Gestagen ,Tamoxifen ,GnRH agonists
4-Chemotherapy: e.g, Adriamycin , cisplatin ,carboplatin

Prognosis
-Generally good prognosis → early symptoms and late lymphatic spread
-5 year survival: Stage I G1 : 95 % cure rate. Stage IG
2
: 75-85%.
Stage IG
3
: 50-60%. Stage II : 40-50 %.
Stage III : 20-30 %. Stage IV : 5-10%.
-Prognostic factors :
1-Age : younger women have better prognosis.
2-Tumor factors:
→ Histologic type : non-endometrioid :high risk → grade. → Tumor size.
3-Uterine spread:
→ Myometrial invasion. → Lymph-vascular space invasion. → Isthmus-cervix extension.
4-Extra uterine spread:
→ Adnexal involvement. → Lymph node metastasis. → Peritoneal cytology (+ve)
5-Tumor charcters:
→ Hormone receptor status. → DNA ploidy pattern (euploid or aneuploid). 
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60. Chorio carcinoma: origin , pathologic features (N/E/M/E), spread, FIGO staging,Diagnosis
( symptoms signs, special investigations, treatment: surgery and chemotherapy). -
Methotrexate therapy: mode of action, indications, , dosage , side effects,
monitoring.(account).
Origin :
• 50% of cases follow vesicular mole.
• 25% follow abortion or ectopic pregnancy.
• 20% follow normal pregnancy.

Pathologic features :
A-Types :
1-Invasive and metastatizing mole:
-15% of vesicular mole invades the myometrium by : → Direct invasion.
→ Spread via venous channels.
-15% of invasive mole show benign distant metastasis, commonly in the lungs.
2-Choriocarcinoma:
N/E :
-Soft symmetrically enlarged uterus occupied by a mass w' is purple ,friable , with
areas of haemorrhage & necrosis .
-It may invade the myometrium & even perforate the uterus.
-Ovaries → theca lutin cyst . (vesicular mole ﻦﻣ ﺐﺘﻜﺗ)

M/E:
-Sheets of malignant cyto- and syncitiotrophoblast with areas of hage & necrosis.
-There is variable degree of myometrial invasion.
-Absence of intact villi (pathognomonic) + Areas of Arias Stella reaction .
-Theca lutin cyst : lined by granulosa & theca lutin cells .
3-Placental site tumor : (from cytotrophoblast only)
-Rare locally malignant tumor that arises from the trophoblasts at the placental site.
-It produces little amount of HCG and HPL & contains little hemorrhage & necrosis.
-Although locally malignant, it can invade the myometrium & myometrial blood
vessels. Treatment is always by hysterectomy as the tumor is chemoresistant.


Spread
1-Local spread :
-To myometrium even perforating uterus , tubes & ovaries .
2-Blood spread : (Main roote)
-Lung (80%) → canon ball metastases , military shadows & malignant pleural effusion.
-Vagina & vulva (50%) → hemorrhagic nodules .
-Liver , bone , brain (20%) .
3-Lymphatic spread : (late)
-As endometrial carcinoma .
 
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FIGO staging (Clinical Staging):(FIGO, 2000)

Stage I:
-Disease confined to the uterus.
Stage II:
-Genital extension (Vagina and Pelvic organs).
Stage III:
-Lung metastases + genital metastasis.
Stage IV:
-Distant metastasis affecting other organs.

Diagnosis
Symptoms
pregnancy event (V.M ,abortion , FTND, witnin 1 1/2 years), followed by :
1-Bleeding : (Most common symptom) , it may be : → 2ry post partum.
→ Post abortive .
→ Metrrorhagia .
2-Symptoms of lung metastases : Hemoptysis & cough .
3-Pain : Acute abdomen : perforation or complicated ovarian cyst .
4-Others :
-Asymptomatic : early in the disease .
-Vaginal discharge : serous, serosangenous then offensive (infection & necrosis)
-Cachexia.
-Symptoms of distant metastases : bone aches & path. fractures , vaginal masses…etc
-Abdominal enlargement : rare .
Signs :
A-General examination :
B-Abdominal examination :
C-Local examination
1.-Uterus : soft & symmetrically enlarged .
2-Adenexal swelling : theca lutin cyst .
3-The vagina : careful examination.
Special investigations
A-Early detection :
-Proper follow up of vesicular mole with early detection of choriocarcinoma (ﺐﺘﻜﻳ)
B-Investigations for established cases :
1-Endometrial biopsy :
2-Serum β-HCG : Serum β-HCG / CSF β-HCG ratio >60.
3-US :To detect myometrial invasion & ovarian cysts .
4-Investigations to detect metastasis : as before +
→ especially Chest X-ray & CT chest .
→ Isotope labeled antihCG antibodies & doppler velocimetry .
5-Preoperative investigations :
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Treatment
A-Prophylactic :
-Follow up of every case of vesicular mole.
-Prophylactic chemotherapy in certain cases of vesicular mole . (indication ﺐﺘﻜﺗ)

B-Curative :

Main line of treatment is chemotherapy
Scheme for TTT :
Stage I :
Fertility desired → single agent chemotherapy , if failed
→ combination chermotherapy
(+follow up of β-HCG till 3 successive –ve results then COCs for 1 y)
Fertility not desired → hysterectomy + single agent chemotherapy
(hysterectomy alone in placental site tumor)

Stage II & III :
For primary : Low risk → as stage I
High risk → multimodal approach (chemotherapy , surgery ,radiation)
For secondary : Vaginal → local resection or selective embolization of int. iliac
Lung → local resection(lobectomy) + combination chemotherapy .

Stage IV:
For primary : combination chemotherapy .
For secondary : Liver → local resection Or selective embolization of hepatic art.
Or local chemotherapy.
Brain → intrathecal chemotherapy or irradiation .

1-Chemotherapy : (TTT of choice as it preserve fertility)
I.Methotrexate: (The most commonly used)

II-Actinomycin D:
-It is an antibiotic that intercalates DNA strands.
-It is effective as a single agent in non metastatic GTT.


III-Other chemotherapeutics : cyclophosphamide, vincristine, etoposide.

IV-Combined Regimens:
-M-EA :
→ Methotrexate - etoposide (OR actinomycin D).
-EMA-C :
→ Etoposide - methotrexate - actinomycin D - cyclophosphamide (OR vincristine) .

2-Surgery : (not TTT of choice as it doesn't preserve fertility)


 
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Methotrexate therapy
Indications ةدﺎﻳز مﻼآ ﻪﻴﻓ
1) The most commonly used TTT of choice of Chorio carcinoma as it preserve fertility 
2) It is still the mainstay for the treatment of many neoplastic disorders including acute lymphoblastic
leukemia.
3) Medical termination of pregnancy
4) Other uses
- Autoimmune diseases, including Myasthenia Gravis, polymyositis, dermatomyositis, inclusion
body myositis, ankylosing spondylitis, Crohn's disease, psoriasis, pustular psoriasis, psoriatic
arthritis, rheumatoid arthritis, Wegener's granulomatosis, and scleroderma
- A parallel use with TNFα blockers such as infliximab or etanercept has been shown to
markedly improve symptoms.
- Behçet's disease where it is taken weekly, along with folic acid daily.
Mode of action
-Folic acid antagonists → (--) dihydrofolate reducatase enzyme required for processing
folic acid to folinic acid → arrested synthesis of DNA, RNA & proteins.

Dosage
- 1mg/kg body weight for 5 days course , courses are repeated every other week.
- Repeat courses till hCG is negative and then add 3 courses after negative titre.
-Leucovorin rescue : administration of leucovorin (folinic acid) after 24 hours of
methotrexate administration to rescue normal cells from methotrexate toxicity.
Side effects
→ BM suppression : decrease in platelets, WBCs and RBCs.
→ Hepatoxicity.
→ Nephrotoxicity.
→ Ulcerations of mouth and GIT mucosa.
→ Nausea vomiting and diarrhea.
→ Alopecia.
Monitoring
(stop drug if WBCs <3000 , platelets <100000, impaired liver & kidney functions)

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61. Ovarian swellings: classification ( non- neoplastic & neoplastic, benign & Malignanent) .
Origin of ovarian tumors: epithelial tumors, C.T tumors ,germ cell tumors, sex cord &
stromal tumors, high risk factors for ovarian maligmant tumors, spread of ovarian
cancer(MCQ)
FIGO staging of ovarian carcinoma , criteria of malignancy of ovarian tumors. ,differential
diagnosis, special investigations, Prophylactic treatment .treatment of stage I ,II , III, IV
ovarian cancer.(account).
FIGO staging of ovarian carcinoma
Stage I Growth limited to the ovaries
Stage I a : Growth limited to one ovary;
(no ascites , (-ve) peritoneal cytology , capsule intact)
Stage I b : Growth limited to both ovaries;
(no ascites , (-ve) peritoneal cytology , capsule intact)
Stage I c : Tumor either stage I a or I b +
Ascites OR (+ve) peritoneal cytology OR capsule not intact
Stage II Growth involving one or both ovaries with pelvic extension.
Stage II a : Extension and/or metastases to the uterus and/or tubes.
Stage II b : Extension to other pelvic tissues.
Stage II c : Tumor either stage II a or II b +
Ascites OR (+ve) peritoneal cytology OR capsule not intact
Stag III Peritoneal & lymphatic spread (+ superficial liver metasases)
Stage III a : Microscopic peritoneal seedling + (-ve) LNs .
Stage III b : peritoneal seedling <2 cm + (-ve) LNs.
Stage III c : peritoneal seedling >2 cm &/or (+ve) LNs .
Stage IV Distant metastasis
Including parynchemal liver metastases .If pleural effusion is present,
there must be positive cytologic test.

 
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Criteria of malignancy of ovarian tumors يﻮﻔﺷ و يﺮﻈﻧ اﺪﺟ مﺎه
A-History :
-Age : the older the patient , the higher the chance of being malignant .
-Rate of growth : rapidly growing tumors are usually malignant .
-Back pain : may suggest advanced malignancy involving the roots of sacral plexus.

B-Examination :
-Malignant cachexia .
-Vircow's glands enlargment
-Unilateral edema : venous or lymphatic obstruction by tumor.
-Ascites : especially if hemorrhagic on paracentesis .
-Umblical nodules
-Solidity or variegate consistency .
-Fixation .
-Bilaterality .
-Nodules in Douglas pouch

C-Investigations :
-US : Bilateral , heterogenous in consistency , multilocular , papilla , dopler studies .
-Metastasis .
-Cytology from aspired ascites .

D-On laparatomy :
-Bilaterality & solidity & fixation .
-Exophytic growth on the capsule or its rupture by the tumor .
-Great blood vessels on surface of the tumor
-Evidence of metastasis
-Peritoneal & omental deposits
-Paraaortic LNs .
-Frozen section .

Differential diagnosis
A-From other causes of pelvi-abdominal swellings.
B-From other causes of adenexal swellings .
C-From other causes of nodules & masses in Douglas pouch .
Special investigations
A-Screening & early detection :
-Screening of high risk patients , by :
1-Annual pelvic examination : less effective.
2-Radiological : (accuracy nearly as D & C)
→ TVS : very high sensitivity for detection of early cancer ovary .
→ Trans vaginal color flow doppler : to assess vascularity of ovarian vessels .
3-Cytology :
→ culdocenthesis .
→ paracentesis (if there is malignant ascites).

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4-Tumor markers :
a-Common epithelial tumors :
-CEA : non specific & insensitive .
-CA 125 → can detect 50% of stage I & 60% of stage II
→ specificity is improved if combined with TVS & serial measurement .
B-Germ cell tumors :
-αFP
-hCG
-LDH .
–α-1 antitrypsin
-Placental alkaline phosphatase(PLAP)
C-Sex cord stromal tumors :
-Estrogen
-Androgen
B-Investigations for established cases :
1-Staging laparatomy :
-Laparatomy remains the main method for diagnosis , staging , ttt & follow up.
-Technique : (ﺐﺘﻜﻳ)
2-US, CT and MRI : only suggestive
3-Investigations to detect metastasis :
4-Preoperative investigations :

Prophylactic treatment
-Early detection.
-Gonadectomy for dysgenetic gonads.
-Immediate management of any ovarian swelling in post menopausal lady .

Treatment of stage I ,II , III, IV ovarian cancer
Main line of treatment is surgery
Scheme for TTT :
Epithelial tumors:
Stage Ia grade 1 : Fertility desired : unilateral oophorectomy .
Fertility not desired : TAH +BSO .

Stage Ia (grade 2,3) , Ib , Ic , II a :
TAH +BSO +postoperative combination chemotherapy or radiotherapy .

Stage IIb , IIc : Radical oophorectomy +postoperative chemotherapy &/or radiotherapy

Stage III , IV : Debulking + postoperative combination chemotherapy , radiotherapy ,
immunotherapy or palliative therapy .

Sex cord stromal tumors:
As epithelial tumors : but chemotherapy & radiotherapy are not recommended .

Germ cell tumors:
As epithelial tumors : but → try to preserve fertility as you can .
→chemotherapy is different (see below) .
→dysgerminoma is very radiosensitive , & can be TTT by
chemotherapy in metastatic cases .

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1-Surgery :
A-Unilateral oophorectomy :
-Indications : stage Ia grade 1 in patients desiring fertility .
(TAH +BSO should be done immediately after minimum completion of the family)
B-Radical oophorectomy :
-Indications : stage IIb , IIc .
-Technique : TAH + BSO +removal of pelvic peritoneum +removal of bladder or recum
with the tumor if affected .
C-Debulking operation : (cytoreductive surgery)
-Aim : remove as much as possible from the malignant tissue to help the postoperative
adjuvant therapy to give the best results .(palliative surgery)
-Benefits : facilitate postoperative chemo or radiotherapy .
Relieve intestinal obstruction
Decrease risk of infection
Improve rectal or bladder functions
-Indications : Stages III , IV .
-Technique : TAH + BSO + remove as much as you can from affected organs (e,g,
omentectomy +remove rectum , colon , bladder , ….etc)
-Optimal debulking : residual tissue < 2 cm .(→ for postoperative chemotherapy)

D-2
nd
look laparatomy :
-Aim : assessment of a patient who has no clinical evidence of disease & (-ve) tumor
markers at the completion of chemotherapy .
-Technique : laparatomy or laparoscopy .

2-Chemotherapy :
A-For epithelial tumors :
-Single agent :
Drug of choice : alkylating agents e.g, melphalan 0.2mg/kg/d for 5 days every 28 days .
Others : cisplatin , carboplatin , paclitaxil , cyclophosphamide, doxorubicin .
-Combination chemotherapy : e.g,
PT : cisplatin + pactilaxel
CT : carboblatin + pactilaxel
PAC : cisplatin + doxorubicin + cyclophosphamide
(intraperitoneal chemotherapy : for small superficial peritoneal depositis → cisplatin)
B-For germ cell tumors :
BEP : bleomycin , etoposide , cisplatin .
VBP : vinblastine , bleomycin , cisplatin
VAC : vincristitine , actinomycin D , cyclophosphamide
3-Radiotherapy :
-Whole abdominal irradiation .
-Intraperitoneal radiotherapy : radioactive gold or phosphorus linked to colloidal carrier .
4-Immunotherapy :
-Non specific : BCG or corynebacterium Parvum .
-α-interferon : SC or intraperitoneal .

 
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62. Enumerate: Ovarian tumors in childhood, functioning Ovarian tumors, Ovarian tumors
causing bleeding, ovarian T causing amenorrhea, post menopausal bleeding due to ovarian
T, malignant Ovarian Ts, solid Ovarian ts , types of ovarian cysts ( retention cysts ,
inflammatory cysts, chocolate cysts, neoplastic cysts, Warthard inclusion cysts),
complications of Ovarian Ts , tumor markers.(account).
Ovarian tumors in childhood
1- Non neoplastic: Functional cysts.
2- Neoplastic:
a- Benign:
i- Dermoid (represents 20-50%).
iii- Papillary serous cystadenoma.
b-Low malignant tumors:
i- Granulosa cell tumors.
iii- Stromal luteoma.
c- Malignant:
i- Malignant teratomas.
iii- Embryonal carcinomas.

Functioning Ovarian tumors
1- Granulosa cell tumor (Estrogen and inhibin).
2- Theca cell tumors (androgens).
3- Androblastomas (Androgens).
4- Gynandroblastoma (androgens and estrogens).
5- Choriocarcinoma (human chorionic gonadotrophin).
6- Struma overii (thyroid).
7- Carcinoid tumor (serotonin).
8- Endodermal sinus tumor : α FP
9- Embryonal carcinoma : α FP , HCG , LDH
10-Stromal luteoma (Androgens)
11-Lipid cell tumors (Androgens).
12-Mixed tumors with any of the above elements.
13-Brenner (controversial activity secreting estrogen or androgen).

Ovarian tumors causing bleeding
-Any tumer has these features :
→ estrogen secreting ovarian tumor
→ direct extension to the uterus.
→ associated endometrial hyperplasia or carcinoma .
As:
1) Granulosa cell tumour
2) Theca cell tumour
3) brenner tumour
4) Twisted Ovarian Tumour
5) malignant ovarian tumours with metastasis to uteru

 
ii- Simple serous cysts
iv- Mucinous cysts.

ii- Androblastomas.
iv- Dysgerminoma.

ii- Endodermal sinus tumor
iv- Choriocarcinoma.
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Ovarian Tumers causing amenorrhea
- Virilizing tumours as androblastoma , hilus cell tumour , adrenal like tumour of the ovary
- Advanced malignancy causing cachexia
- Bilateral diffuse fibromata
- Androgen producing tumers: as:
- Theca cell tumors (androgens).
- Androblastomas (Androgens).
- Stromal luteoma (Androgens)
- Lipid cell tumors (Androgens).

Post menopausal bleeding due to ovarian Tumers
→ estrogen secreting ovarian tumor ( granulosa cell tu. ,gyandroblastoma )
→ direct extension to the uterus. (malignant ovarian tumours with metastasis to uterus)
→ associated endometrial hyperplasia or carcinoma . (endometrial carcinoma with metastasis to ovary)

Malignant Ovarian Ts
1-Common epithelial tumors : (90% of ovarian cancers)
Serous (75%) : Cystadenocarcinoma. Adenocarcinoma. Surface papillary carcinoma.
Mucinous (20%) : Cystadenocarcinoma. Adenocarcinoma.
Endometrioid (2%) : Adenocarcinoma. Adenoacanthoma.
Clear cell (mesonephroid) carcinoma.
Malignant Brenner tumor.
Mixed malignant carcinoma.
Undifferentiated & unclassified adenocarcinoma.
2-Germ cell tumors :
All are malignant : except mature cystic teratoma (dermoid cyst).
-dysgerminoma
- emberyoma
- yolk sac tu.
- choriocarcinoma
3-Sex cord stromal tumors :
Granulosa cell tumor .
Sertoli cell tumor .
4-Ovarian sarcoma .
5-Metastatic carcinoma .

 
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Solid Ovarian Tumers
1) Epithelial cell tumer ( germinal ) :
- brenner tu
2) Germ cell tumer :
- dysgerminoma
- emberyoma
- yolk sac tu.
- choriocarcinoma
3) Sex cord stroma cells tu :
- granulosa theca cell tu.
- gynadroblastoma
- androblastoma
- lipoid cell tu .
4) Metastatic tu
5) Other : (Benign)
- mesothelioma
- luteoma of pregnancy
- fibroma
- hilus cell tumor
- lymphoma

ﻆﻔﺤﺗ ﻻ ﻰﺘﺣ ةﺪﻋﺎﻘﻟا
All ovarian tumors are solid except the following:
1- Benign and borderline serous cystadenoma.
2- Benign and borderline papillary serous cystadenoma & cystadenofibroma.
3- Benign and borderline mucinous cystadenoma.
4- Benign and borderline papillary mucinous cystadenoma.
5- Benign and borderline mucinous cystadenofibroma.
6- Mature cystic teratoma.
 
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Types of ovarian cysts ؟؟؟ﻲﺼﺨﺷ دﺎﻬﺘﺟا
Non Neoplastic Cysts
1. Functional cysts (or simple cysts, are part of the normal process of menstruation)
 Graafian follicle cyst
-It is lined by granulosa cells.
-Usually represent a distended atretic follicle.
-More commonly found with: → Ovulation induction.
→ Ovarian hyperstjmulation syndrome.
→ Use of progestagen-only contraceptives e.g, POPs
 Corpus luteum cyst
-Frequently represents a cystic CL lined by granulosa-lutein &/or theca lutein cyst.
-It may delay menses.
-It may rapture causing acute pelvic pain associated with a bleeding episode.
→ DD with disturbed ectopic.
 Theca-lutein cysts
-It results from excessive hCG stimulation → vesicular mole or choriocarcinoma.
-It is multiple and can reach large dimensions & lined by luteinized theca cells.
 Hemorrhagic cyst =Blood Cyst
- when a very small blood vessel in the wall of the cyst breaks, and the blood enters the cyst
2. Chocolate cyst=Endometrioid cyst: : 
-The ovary is the most frequent site.
-It rarely exceeds the diameter of 10 cm but can be multiple.
-Frequently bilateral & associated with pelvic adhesions and endometriotic deposits
on other pelvic structures.
-Filled with thick, brown fluid similar to liquid chocolate & lined by endometrial epithelium.
-It usually ruptures during attempt at removal.
3. Inflammatory cysts = Tubo-ovarian abcess :
- pus-filled pocket involving a fallopian tube and an ovary
- causing symptoms of pelvic inflammatory disease or abdominal pain.
- The infection is usually accompanied by fever, and the patient will appear ill.
- Treatment is generally with antibiotics. In some, surgery may be required to remove the pus.
4. Warthard inclusion cysts ا آ ﻴ ﺪ ﻓ ﻴ ﻪ ﺧ ﻄ ﺄ ا ﻣ ﻼ ﺋ ﻲ ﻻ ن ه ﺬ ة ا ﻟ ﻜ ﻠ ﻤ ﺔ ﻻ أ ﺻ ﻞ ﻟ ﻬ ﺎ
Germinal inclusion cyst =Are possible precursor lesions for epithelial ovarian cancer. These cysts have
been postulated to form as stigmata of ovulation.
=the presence of a bizarre lump-shaped cyst with a thin wall and fine internal septations with an ovary
suspended among adhesions
5. Pathological Cysts:
- Polycystic ovary syndrome.
The cysts develop due to a problem with ovulation caused by a hormone imbalance. PCOS
is associated with period problems, reduced fertility, hair growth, obesity, and acne
- Other associated with tumers

 Retention cysts =tumor-like accumulation of a secretion formed when the outlet of a secreting
gland is obstructed.
Neoplastic cysts
 Benign and borderline serous cystadenoma.
 Benign and borderline papillary serous cystadenoma & cystadenofibroma.
 Benign and borderline mucinous cystadenoma.
 Benign and borderline papillary mucinous cystadenoma.
 Benign and borderline mucinous cystadenofibroma.
 Mature cystic teratoma .( Dermoid cyst) It is common: 10% -15% of ovarian tumors
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Complications of Ovarian Tumers :
1-Torsion of the pedicle:
Predisposing factors: → Small to moderate size.
→ Long pedicle (as with dermoid cyst).
→ Fixation of the tumor at one point .
→ Pregnancy & puerperium : because of rapid change tumor position .
Precipitating factors :→ Straining during defecation or labor .
→ Turning over in bed
→ Sexual intercourse.
Pathophysiology :
-At the beginning the venous flow is impeded → sudden congestion.
(which may precipitate intra cystic hemorrhage).
-Later, the arterial flow is impeded → tissue necrosis and gangrene.
-The tube is usually involved with torsion of ovarian tumor.
-Minimal torsion may result in adhesion of the tumor to the abdominal wall or intestines.
C/P : acute pain + tender mass in the lower abdomen.
By US fluid is usually found in the peritoneal cavity.
Treatment: Immediate laparatomy:
1. If the tumor looks gangrenous: Salpingoophorectomy is done.
2. If the ovary looks healthy: Cystectomy and conserving viable ovarian tissue.
2-Rupture :
Predisposing factors : Torsion or hemorrhage. May be precipitated by external trauma.
C/P : depends on the contents :
Papillary cystadenoma → Ascites
Mucinous cyst → pseudo myxoma peritonii
Dermoid cyst → chemical peritonitis
Infected cyst → septic peritonitis
Hemorrhagic cyst → internal hemorrhage .
Treatment: Immediate laparatomy:


3- Hemorrhage:
Predisposing factors :Torsion , infection & trauma.
C/P : acute abdomen, & rapid enlargement of the tumor .
Treatment: Immediate laparatomy:

4-Infection :
Predisposing factors :Torsion , hage or tapping ovarian cyst especially during puerperium.
C/P : FHMA + peritonitis if reaching the peritoneum .
• Clinically:
1. Severe pain.
2. Severe systemic toxemia and fever because the pus is held in a closed space.
• Omental and intestinal adhesions may make removal of the tumor difficult.

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5-Impaction in the pelvis : (incarceration)
Predisposing factors: → Small to moderate size + Long pedicle.
Precipitating factors : adhesions or growing pregnancy.
C/P : → Pelvic pain.
→ Rectal pressure or constipation.
→ Irritability of the bladder & urinary retention.
→ It can obstruct labor.

6-Intestinal Obstruction :
-Due to adhesions or infiltration .
-Mostly with malignant tumors (main cause of death) rarely with benign tumors .

7-Malignant Changes :
-Malignant change may occur in some benign ovarian tumors, particularly in cystadenoma.

8-Meig's & pseudo Meig's syndrome :
-Meigs ' syndrome : ovarian fibroma + Ascites + Rt. hydrothorax .
-Pseudo Meigs' syndrome : any benign solid tumor other than fibroma (e.g, Brenner ,
uterine fibroid ) + Ascites + Rt. hydrothorax .

9-Pseudo myxoma peritonei :
Cause : Mucinous cystadenoma
Mucinous cystadenocarcinoma
Mucocele of the appendix
Well differentiated cancer colon
Pathology :The peritoneal cavity is filled with a huge amount of mucinous material
→ extensive adhesions.
TTT : It may need radiotherapy or intra peritoneal instillation of radio-active isotope.

Tumor markers
a-Common epithelial tumors :
-CEA : non specific & insensitive .
-CA 125 → can detect 50% of stage I & 60% of stage II
→ specificity is improved if combined with TVS & serial measurement .
B-Germ cell tumors :
-αFP
-hCG
-LDH .
-α-1 antitrypsin
-Placental alkaline phosphatase(PLAP)
C-Sex cord stromal tumors :
-Estrogen
-Androgen
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63. Dysparonea: definition, types , causes. (MCQ).







64. Hirsutism : androgen production in female , definition of hirsutism, causes of
hirsutism.(MCQ).






 

65. Enumerate lower urinary symptoms in female, types of incontinence of urine in
female.(MCQ).







66. Causes of chronic pelvic pain ( gynecologic & non gynecologic).Causes of low back pain (
gynecologic & non gynecologic).(MCQ).








67. Hysterectomy: types , approaches, indications in gynecology & obstetrics. (MCQ).

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