Mullerian Duct Abnormalities

 Mullerian ducts is responsible for forming most of the female reproductive tract and includes
the fallopian tubes, uterus, uterine cervix and superior aspect (upper 2/3) of the vagina
 Most MDA present in the pubertal period because of menstrual difficulties, infertility or
obstetrical complications
 Embryology
at 6 weeks, 2 ducts are present i.e. Mullerian and Wolffian ducts however the wolffian duct
degenerates if no testosterone is present and mulerian duct elongates
At 9 weeks forms 3 recognisable regions
(1) Cranial vertical fumbria of fallopian tubes
(2) Horizontal Fallopian tubes
(3) Caudal vertical uterus, uterine vervix and superior vagina
 Some examples of Mullerian Duct Abnormalities
1. Segmental or complete agenesis
2. Vaginal agenesis (mayer Ro
3. Unicornuate uterus
4. Complete/partial bicornuate uterus
5. Arcuate uterus
6. DES related abnormalities

Hirsutism

 Is a condition where women have excess facial and body hair that is dark and coarse. The
abnormal hair growth usually happens on the body where men typically have hair eg chest,
back, face
 Patients may have high levels of make androgens and may indicate an underlying pathology
 Signs and symptoms
1. Male pattern hair growth
2. Irregular menstrual periods
3. Loss of genuine body shape
4. Sign of masculinity deepening voice, male pattern badlness, enlarged clitoris, enlarged
shoulder muscles
5. Hirsutism due to cushings obesity around the middle section, high BP, diabetes,
thinning skin
 Causes
1. Polycystic ovary syndrome
2. Tumors of the adrenal glands
3. Cushing syndrome
4. Medications eg phenytoin, midoxil, danazol, steroids
Dx Blood test for hormones level (testosterone,DHT, DHEA-S)
CT/MRI/pelvic ultrasound

Bacterial Vaginosis

 a condition where the normal balance of bacteria in the vagina is disrupted

 normal lactobacillus in the vagina is replaced by high concentrations of anaerobic bacteria e.g.
bacteriodes
 patient complains of vagina discharge that is thin, white and foul smelling with no pruritis
 on speculum examination reveals a homogenous grayish white, watery discharge that yields a
fishy odor upon mixing with KOH (positive whiff test)
 vagina pH >4.5
 Saline smears clue cells
 Rx 5-7day metronidazole
 Bacterial vaginosis increases the risk of PID, choriaminonitis, premature birth, premature
rupture of membranes and postpartum endometritis

Intrauterine contraception Devices (IUCD)

 A form of birth control in which a T shaped device containing copper or progesterone is inserted
in the uterus
 Are a form of long acting reversible contraception
 Copper IUCD disrupts sperm mobility and damages sperm s that they are prevented from
joining with an egg. It’s a natural spermicide within the uterus, increasing levels of copper ions,
prostaglandins and WBC within the uterine and tubal fluids. The increase copper ions in the
cervical mucus inhibits the sperm’s mobility and viability preventing sperms from travelling
through the cervical mucus .
Advantages
1. Non hormonal
2. Provides emergency contraception up to 5 days of unprotected sex
3. Can be sued with breastfeeding
4. Fertility returns quickly after removal

Disadvantgaes

1. May cause heavier menstrual bleeds

2. More painful cramps
 Hormonal IUCD it releases levonrgestrol (progestin) and may be used up to 5-7 years. The
reduce menstrual bleeding and prevent menstruation altogether and can be used in the
treatment of menorrhagia. It releases hormone ar a rate of 20 micrograms/day and 14
 micrograms/day after 5 years
The hormone functions by
1. Thickening cervical mucus
2. Inhibit sperm’s survival and ability to penetrate the egg
3. Suppress the endometrium
4. Inhibits the ovulation

Menorrhaga uterine bleeding occurring cycling at regular intervals, excessive amount and or duration

 Excessive uterine bleeding occurring at regular intervals

 Dx history and physical examination
 Confirming diagnosis of menorrhagia and if any other organic cause
1. CBC gives an indication of any hematological disease
2. TFT if long with history and physical examination if you are suspecting hypothyroidism
3. Other endocrine test progesterone/goandotrophins
4. Test for bleeding/clotting
5. Endometrial biopsy
6. Pelvic ultrasound fibroids/polyps
7. Hysteroscopy & direct biopsy
 Rx
1. 1st line progestogens or OCPs
2. 2nd lineDanazol, GnRH analogues
3. If medical therapy fails then endometrial ablation techniques

Dysfunctional uterine bleeding irregular uterine bleeding that occurs in the absence of pathology or
medical illness and is a diagnosis of exclusion. It is a disruption in the normal cyclic pattern of ovulatory
hormonal stimulation to the endometrial lining. Bleeding may be excessively heavy, light, prolonged,
frequent or random

 Dx
1. Lost of cyclic endometrial stimulation that arises from the ovulatory cycle
2. Patient have constant non cycling estrogens levels that stimulate endometrial growth
3. Proliferation without shedding causes the endometrium to outgrow its blood supply
4. Which results in tissue break down and sloughs off uterus

Investigation

 Unpredictable/episodic heavy/light bleeding despite normal pelvic examination

 Screen for personal or family history of bleedin diathesis
 Iatrogenic causes steroid hormone/hormone replacement therapy
 Examination of organic causes
1. PCOS
 2. Adrenal enzyme defects
3. Thyroid disease
4. Metabolic disease
 Obesity
 Sign of androgen excess e.g. acne, hirsutism
 Signs of hypo/hyperthyroid
 Galactorrhea
 Visual field pituitary lesion

Labs HCG, CBC, pap smear, endometrial biopsy, TFTs, Prolactin, LFTs, coagulation profile

Pelvic U/S

CT of pituitary fossa

RX 1st line OCPs, then if failed surgery (hysterectomy or endometrial ablation techniques)

Cervical Intraepithelial Neoplasia

Abnormality of the cells in the transformation zone (squamocolumnar junction) which usually as a result
of HPV infection (subtypes 16, 18)

CIN is usually asymptomatic but it is a premalignant lesion

CIN I mid nuclear abnormalities confined mainly to the lower 3 rd of the epithelium

CIN II increasing nuclear abnormalities involving mainly the basal 2/3 of the epithelium

CIN III makred nuclear abnormalities that are present throughout the entire thickness of epithelium
and is also known as carcinoma in situ and is a premalignant lesion

DX

1. Direct visul examination with acetic acid (VIA)

2. Pap smear
3. Colposcopy and directed punch biopsy
4. Cone biopsy

RX

1. CIN I cryotherapy, abstinence for 6 weeks, give antibiotics

2. All CIN LEEP procedure of the transformation zone