Method Recommendations 4

STATE ESTABLISHMENT
"DNІPROPETROVSK MEDICAL ACADEMY OF THE MINISTRY OF HEALTH OF

UKRAINE"
OBSTETRICS AND GYNECOLOGY DEPARTMENT
DISCIPLINE “OBSTETRICS AND GYNECOLOGY”
METHODICAL GUIDELINES
for practical lesson
4 course
DISEASES OF FEMALE REPRODUCTIVE SYSTEM

FAMILY PLANNING
GUIDELINES WERE APPROVED AT A MEETING OF THE DEPARTMENT OF

OBSTETRICS AND GYNECOLOGY (PROTOKOL №______)______ _______ 2015
The Chief of the Department
of Obstetrics and Gynecology ______________________Professor V.O.Potapov
GUIDELINES WERE REVISED AT THE MEETING OF THE DEPARTMENT OF

OBSTETRICS AND GYNECOLOGY
GUIDELINES WERE REVISED AT THE MEETING OF THE DEPARTMENT OF

OBSTETRICS AND GYNECOLOGY
4 course

FAMILY PLANNING
Topic 1. PHYSIOLOGY OF THE FEMALE GENITALS ORGANS. METHODS OF

EXAMINATION GYNECOLOGICAL PATIENTS. ROLE OF FAMILY DOCTOR TO
AWARD OBSTETRIC CARE.
Amount of hours: 3 hours in practical classes
I. Scientific and methodical grounds of the theme.

Professional motivation: clinical anatomy of the genitals has a great value for studying
gynecology. The structure of external and internal genitals, their blood supply enables to
understand pathogenesis of gynecologic diseases.
Basic level:
1. External female genital organs
2. What specialist consults women with pathology of the female genital organs?
3. How often can medical conditions complicate the course of pathology of the female genital
organs?
II. Aim:
A student should be know to:
- The principles of organization and provision of obstetric care in Ukraine (order
№41,7620);
- The function of the family doctor to provide obstetric care
- Clinical anatomy of the female genital organs.
- Physiological changes in the female genital organs in different age periods.
- Regulation of neuroendocrine function of the reproductive system.
- The collection features special gynecological history.
- Basic examination methods in gynecology: an overview of the external genitalia, studies
using mirrors, bimanual examination.
- Methods diagnostics of functional ovaries.
- Ray diagnostic techniques in gynecology: MRI, CT, MSH.
- Ultrasonic methods in gynecology.
- Instrumental methods of inspection: probing the uterus, uterus curettage, biopsy, puncture
of the abdominal cavity through the rear arch.
- Endoscopic methods: colposcopy, hysteroscopy, laparoscopy. Laboratory diagnosis:
oncocytology, bacterioscopy, bacteriology, ELISA, PCR, pathologic study.
- General gynecological diseases symptomatology (pain, discharges, menstrual cycle and
bleeding, infertility, sexual disorders, disorders of adjacent organs).
A student should be able to:
- Familiarity with the work gynecological department;
- Registration of medical records, on receipt of gynecological patients to hospital.
- Introduction to the provision of gynecological care for women according to the order of
Ministry of Health of Ukraine № 620 and 417
III. Recommendations to the student

METHODS OF EXAMINATION IN GYNECOLOGY
Examination of gynecological patient consists of history taking, objective (general and

special) and additional methods of examination. The examination begins with obtaining the
history in accordance with a certain plan.
First of all, the passport data is required: surname, name, patronymic, and also birth date
(woman's age). This is done because each phenomenon in different age of women lifecycle can
have different meaning, for example, absence of menses in young women and women in
menopause.
History taking. History has extraordinary value in gynecology. Sometimes it deals with the
intimate life problems, that's why it is necessary to ask a patient delicately and accurately for
obtaining sufficiently full and exact information. Carefully taken history sometimes is sufficient
for making the previous diagnosis. At first patient should be asked about complaints,
development of the disease (anamnesis morbi), life conditions and the previous diseases
(anamnesis vitae). Gynecological history should be taken in such a way.
Patient Complaints. Most often patients complain of pain, pathological secretions from
vagina, bleeding and also of the adjacent organs' dysfunction. The character of pain may point out
the disease: the dull pain arises due to abnormal uterine position and chronic inflammatory
processes of ovaries. Colicky pain appears in case of uterine or tube contraction (tube or uterine
abortion, protruding myoma). Pain has stabbing and stinging character in case of inflammation.
Its intensity becomes more severe that is followed by peritoneal irritation. Such pain appears at
blood presence in abdominal cavity. Pain has an acute, cutting character at uterine tube and
pyosalpinx rupture. Permanent pain is typical for chronic inflammatory diseases and malignant
tumors. Pain appeares in sacrum and dorsal lumbar region in dorsal uterine dislocations
(retropositio uteri), parametritis and perimetritis. In adnexal diseases pain is present in lateral
regions of the lower parts of abdomen. In the diseases of external genital organs pain is situated
in place of lesion. Pain irradiation into sacrum, thigh, supraclavicular region (phrenicus-
symptom) is typical for some gynecological diseases.
Leucorrhea is a discharge from vagina, that is common at inflammatory processes, uterine
disposition and tumors. It is important to pay attention to amount, colour and smell of the
discharge. For instance, at trichomoniasis it has "foamy" character, in case of candidiasis it is
cheese-like, at cervix erosions it has mucous character, and in case of malignant tumors it looks
like "meat slops".
Bleeding can be the manifestation of irregular menstrual cycle, malignant processes and
pregnancy.
The physician should inquire about disorders of adjacent organs such as the character and
frequency of urination (pain, urine incompetence, extremely frequent urination), defecation
(constipation presence, pain at defecation act) and also about the general disorders (hot flushes,
palpitation, dizziness, loss of weight or, to the contrary the obesity).
Gynecologic History (anamnesis morbi). The following questions are typical for gynecologic
history:
• Is the onset of the disease acute or gradual?
• Have you had any previous examinations or treatment? Notes from the previous physicians
may be helpful.
• What were the circumstances at the time when the problem has began (i. e. supercooling,
physical overload, previous abortions and traumas)? Correct taking of gynecological history
gives a possibility to make a previous
diagnosis with sufficient exactness. However, doctor can perform definitive conclusion about
disease only after carrying out an objective examination.
Life history (anamnesis vitae) should define, in which conditions woman has grown up and
was formed and also in which conditions she lives at present. Conditions, in which girl lived from
early age can have effect on the development of the whole organism. Important value has a full-
valued rational feeding, especially in the period of puberty. Excessive or, on the contrary,
insufficient feeding can cause wrong forming of the genital system, menstrual and regenerative
dysfunction. Material-domestic and job conditions have also a great effect on woman's health
state.
Professional and work conditions. There are many professional factors, that have negative
effect on woman's health. First of all this is weight lifting, that can contribute to genital organs
prolapse, long standing on feet can cause blood stagnation in lower extremities and in pelvic
organs causing hypersecretion of mucous membranes. Salts of heavy metals, aniline paints,
varnishes and some other chemical substances and radiation have harmful effect on woman's
health. Most frequently their action causes menstrual and regenerative dysfunction. Mental
overloads can also cause various disorders.
Previous diseases. It is important to find out whether the patient was ill with
tuberculosis and sexually transmitted diseases. It is important to know whether the
operative interventions on abdominal cavity organs took place. Appendectomy in the past
can provoke ovarian inflammation and lately performed appendectomy should be a cause of
adhesion process. Special importance has allergic history, for instance, presence of allergic
reactions on some medicines. The physician should inquire patient about harmful habits
(smoking, alcoholism and drug abuse).
Gynecological history includes data about menstrual, sexual, generative and
woman's secretory functions.
Menstrual history reflects the state of sexual system and organism in a whole. It is
important to establish the patient's age at first menstruation (menarche), the interval from the
first day of one menstrual period to the first day of the next menstrual period (cycle length),
the duration of the menstrual flow, the estimated amount of flow (number of pads) and pain
presence.
Late appearing of menses can point to infantilism. Normal amount of blood loss is about
150 ml. If there is an excessive blood loss, myoma or endometriosis should be suspected.
Menses duration is also increased in these diseases. Painful menses are present if
inflammatory processes, endometriosis is present. It is important to know whether menses
character has changed with the beginning of sexual life, after delivery and abortions.
Interrogating is finished by asking about the character and date of the last menses.
If a patient has menopause it is necessary to specify, at what age it has begun, how the
transitional period passed, whether she has bloody secretions from vagina (this thing can
testify about endometrial cancer).
Sexual history. Special tact should be while inquiring woman about this function. It is
important to know whether the woman is married or not, about the presence of sexual partners,
whether there appeared any signs of disease beginning of sexual life or with partner change.
Patient's contraceptive history should include the contraceptive method currently used, when it
was firstly used, any problems or complications connected with the method and her partner's
satisfaction with the method. It is necessary to ask about the main compounds of sexual
function: sexual appetite, orgasms. In case of sexual dysfunction it is important to know
whether there where any factors that could negatively affect woman's sexual function
(trauma, rape etc.). Some peculiarities of sexual function can give information about
presence of concomitant disease. If there is contact bleeding one can suppose cervical
diseases such as erosion, endometriosis and sometimes cervical cancer. Painful sexual act
can point to the inflammatory processes of peritoneum, ovaries, nearby uterine cellular
space and vaginism.
Generative (childbearing) function. Child birth is the women's basic function. In this part one
ought to find out, in what time after the beginning of sexual life the first pregnancy had happened
without contraception, how many pregnancies were in the past, what was the duration of each one
and how they have finished (with delivery or abortion), whether there were premature births or,
stillborn children. One should know about babies death in early neonatal perаbout the character of
the complications during and after delivery, about the operative interventions during delivery. In
case of performed abortions the patient should be inquired about whether were they artificial (at
woman's desire), spontaneous, or criminal, in what terms pregnancy was interrupted, were there
any complications during and after abortions. If abortions were spontaneous what were their
causes.
Absence of pregnancy for a year of sexual life testifies sterility, that can be a concern of
woman's genital organs abnormality, ovarian dysfunction or result of the inflammatory process.
Rare pregnancy and its frequent loss indicates on hormonal insufficiency. One should
obligatorily find out whether the woman uses contraceptives, which ones and during what time.
Secretory history. Much discharge from genital organs is an indication of the gynecological
diseases presence. It is necessary to know about amount, smell, appearance, discharge periodicity,
because at different gynecological diseases their character differs (due to trichomonal vaginitis
they have "foamy" character, in candidiasis — cheese-like character, in malignant tumors — the
appearance of "meat slops").
Physical examination
It starts from general examination. It is important to pay attention to the colour of skin:
pallor can indicate anemia, ground colour characterizes malignant neoplasm presence.
Excessive hairiness, the lipids dysmetabolism can indicate presence of endocrine diseases.
Dry, coated tongue can indicate to the inflammatory process, "raspberry" one points to
candidiasis.
Attention should be paid to the form of the abdomen (tumors of abdominal cavity, ascitis). It
is importnt to determine whether the abdomen takes part in breathing act. Palpation gives a
possibility to find presence or absence of abdominal wall muscles tensity that is common for
ovarian inflammation, torsion of the pedunculated cystoma. Extension of inflammatory process
from ovaries to peritoneum or blood presence in abdomen causes positive symptoms of peri-
toneal irritation. Deep abdominal palpation reveals tumors or infiltrates in pelvis.
Special attention in examination of gynecological patient belongs to breasts palpation. It
is important to find presence or absence of consolidations in breasts, character of discharge
from nipples. Patient needs additional examination in case of sanious discharge from nipples.
The axillary and inguinal lymphatic nodes should be also examined.
Auscultation of abdomen can be useful to determine of bowels peristalsis i at
pelvioperitonitis it is languid, at peritonitis it is languid or absent). Auscultation й used for
differential diagnostics of pregnancy and tumor.
Each symptom that is found during physical examination should be estimated in complex
with the others.
Gynecologic examination. All the methods of gynecological examination are divided into
basic which are obligatory, and additional those are performed according to certain indications.
To basic methods belong:
• external genital organs examination
• speculum examination
• bimanual (vaginal-abdominal and rectal-abdominal) examination Following methods
belong to additional ones:
• cytological examination
• bacterioscopic examination
• bacteriological examination
• examination with tenaculum
• uterine sounding
• dilatation and curettage with the following cervical canal and uterine histological examination
• culdocentesis
• biopsy, especially aspirative one
• pelvigraphy, especially bicontrast one
• endoscopic methods: colposcopy, cervicoscopy, hysteroscopy, laparoscopy, culdoscopy
• ultrasonography
• functional tests (investigation of ovarian function)
• medical-genetic examination
Basic methods of examination
Gynecological examination is performed on the examination table. Woman lays on back,
with half-flexed legs in femoral and knee joints. It is obligatory to empty the urinary bladder
before examination, in some cases vacuant enema is indicated. Examination is made in sterile
gloves.
Pelvic examination begins with the inspection of external genital organs. Attention should be
paid to pubic hair type (masculinizing, feminizing or mixed type), presence or absence of hair on
the internal thigh surfaces. Skin irritation in the same places can occur at excessive discharge.
Doctor should examine the labia major and labia minor, their size, pigmentation, presence or
absence of edema, ulcers, condylomatous nodes and varicose veins. The degree of pudenda cleft
closing is marked. The labia are spread laterally to examine the outer o; vagina, pigmentation,
colour, presence or absence of ulcers. Estimation of hymer (intact, torn, fresh ruptures) is obligatory.
Making examination of clitoris an attention should be paid to its size. The urethral orifice, the areas
of the urethra and Skene's glands should be examined. Doctor examines whether there are any
secretions, polyps vegetation or hyperemia in this area. The region of the BartO-line's glands should
be inspected. Estimation of their excretive ducts (discharge character, hyperemia, edema around
orifices) is performed. Perineum state, old ruptures presence, scars, hemorrhoid nodes in anus
region, condylomas, fissures, ulcers and mucous membrane are also inspected. Offering a woman to
push doctor should determine the presence or absence of prolapse of vagina or uterus.
After finishing of external genitals inspection vaginal speculum examination is performed. For
this purpose single-blade Sims 'speculum with vaginal retractor or bivalve Cuskoe 's speculum are
used (fig. 20, 21). Recently single-use bivalve specula were used.
Fig. 20. Single-blade Sims Fig. 21. Bivalve Cuskoe's

speculum with vaginal retractor speculum
Bivalve speculum is introduced into vagina with closed values. With thumb and index fingers
of the left hand labia are drawn and speculum is inserted into vagina, placing blades parallel to
pudendal cleft. After insertion speculum is turned on 90°. The speculum is inserted as far as it
goes which in most women means insertion of the entire speculum length. The speculum is then
opened in a smooth delicate way with slight tilting of the speculum, the cervix slides into space
between the blades of the speculum. The speculum is then locked into the opened position using
the thumb screw (fig. 22).
Sims speculum is inserted into vagina in such a way: with left hand labia major and minor are
drawn laterally and with right one the speculum turned, slantwise to pudendal cleft is inserted into
vagina, slightly pressing on perineum. Flat anterior speculum (lateral) should be inserted parallely,
lifting up anterior wall of vagina (fig. 23). Flat speculum should be inserted additionally in case if
vagina is wide and its lateral walls are hanging.
а b с
Fig. 22. Examination of uterine cervix by Cuskoe's speculum:

a — Bivalve Cuskoe's speculum inserted in vagina; b — Bivalve Cuskoe's speculum is
opened; с — incorrect insertion of speculum into vagina
Uterine cervix, its size, shape (cylindrical, conic), shape of external os (round in
nonparous women, fissured in parous ones) (fig. 24) must be inspected. Character of the
cervical mucous membrane (cyanosis, hyperemia), erosions, ruptures, inversions,
condylomas presence, hyperemia around external cervical orifice, secretions
character may be marked.
After cervical examination speculum is gradually withdrawn, inspecting vaginal walls.

Attention should be paid to the state of mucous membrane (hyperemia, edema), discharge
character.
During inspection by Sims speculum at first the elevator, and then the speculum are
withdrawn.
After finishing speculum examination, bimanual vaginal-abdominal (fig. 25) and rectal-
abdominal examination should be performed.
The bimanual (vaginal-abdominal) examination. With thumb and index fingers of the left hand
labia minor are spread. The middle and index fingers of the right hand are inserted into vagina,
nameless and little fingers are pressed to palm, and thumb finger is facing the pubis. An
examination is made by one
finger if vagina is narrow. Fingers during insertion into vagina should be gently pushed
downwards to avoid unpleasant feelings of irritation of the most sensible areas such as anterior
wall, clitoris, region of urethra. During introducing fingers into vagina following signs are
estimated: presence or absence of pain, outer width (in women, which live sexual life, two fingers
enter easily). Determination of the muscles tone and perineum state is performed with pressing on
the muscles of the pelvic floor. During gradual moving of fingers into vagina its length, width,
ability to tension, rugosity, humidity degree, septums presence, tumors, scars, constrictions are
determined. An attention to vaults depth, presence or absence of pain, hanging, shortening should
be paid. After palpation cervical form (cylindrical, conic, deformed), its size (underdeveloped,
normal size or hypertrophied), presence or absence of ruptures, state of external os (opened, closed,
deformed), consistence (dense, sclerosed, softened, of heterogeneous consistence), tumors
presence are determined. Cervical attitude to pelvis axis is also estimated. Then fingers are placed
into anterior vault and cervix is pushed to back. With abdominal hand one should cautiously press
on the front abdominal wall towards fingers those are inserted into vagina. So, uterus is found
between fingers of the abdominal and vaginal hands. If uterus is retroflected, then vaginal fingers
are placed into the posterior fornix.
Uterus is situated in pelvis in such a way that its body and cervix form an angle, opened frontally
(anteflexio), and the whole uterus is flexed forward (ante-versio). It is sufficiently mobile at
displacement attempt. Overmobility of the uterus is observed at its descent and prolapses due to
incompetence of ligament system. Limited movability is common at adhesions and infiltrates
presence in true pelvis.
During uterus examination its size (in nonparous women it is smaller than in parous
ones) is determined. Diminish of the uterus size is observed at genital infantilism and
menopause. Enlarged uterus can be found at pregnancy and tumors presence. Uterine shape
normally is pear-like, flattened in front-back direction, at pregnancy it can be asymmetric
due to protrusion of implantation place, at subserous fibromyoma it is tuberous. Uterine
consistency is tightly-elastic and painless.
Bimanual examination of the adnexa begins with placing the vaginal fingers to the side
of the cervix deep in the lateral fornix. It is important to note that the fallopian tubes are not
palpable. Ovaries can be palpated as elastic painless structures. They are mobile and rather
sensitive. Normal uterine and ovarian ligaments could not determined. Normally there is no
pain and infiltration in paramethrium.
Recto-abdominal examination. In girls, or in case of athresia or stenosis of vagina
recto-abdominal examination is made. This method should be used for more detailed
inspection of pelvic organs tumors. The examination is made by introducing index finger
into rectum. As at previous examination external hand is placed on the anterior abdominal
wall over pubis. Vaginal part of cervix which directly adjoins to the anterior wall of rectum is
palpated. Its size, mobility, uterine and adnexa sizes, sacral-uterine ligaments and
parametriums are palpated.
Additional methods of examination
They are: bacterioscopy examination (smear for purity degree), cytologic investigation
of vaginal smears, bacteriological checkup, methods of functional diagnostics, colposcopy,
biopsy, uterine sounding, fractional diagnostic curettage of cervical canal and uterine cavity
with the following histological research, culdocentesis, pertubation and hydrotubation. X-
ray examination methods such as hysterosalpingography, pelviography and bicontrast
pelviography are also used. Colposcopy, hysteroscopy, laparoscopy and culdoscopy are
endoscopic methods in gynecology. Ultrasonic examination is wide-spreaded nowadays.
These methods are used for verification of the diagnosis. Cytologic investigation is obligatory
for women who undergo monitoring.
Nurse or midwife prepares the woman and necessary instruments (specula, sets for
abrasion, spoons or brushes for smear taking) for carrying out additional examinations. Nurse
must prepare a bottle with 10 % formalin solution for tissual fixation of the biopsy tissue
after curettage. Proper assignment registration on research is of great importance.
Smears from vagina are taken for purity degree, gonorrhea, oncocytologic investigation,
"hormonal mirror".
Following instruments are necessary for material taking:
• vaginal specula
• Folkman's spoon or gynecological spatula or brush
• forceps
• glass slide
• cotton swab
• antiseptic solution
• registration form for laboratory
Patient's preparation:
• to place the patient on examining table
• to make desinfection of external genitalia
• to insert gynecological speculum into vagina, dispose cervix in speculums
Bacterioscopic investigation of vaginal discharge gives possibility to determine vaginal
purity degree, bacterial flora, presence of contraindications to different diagnostic manipulations.
This method gives possibility to diagnose inflammatory process.
Technique of smear taking for examination on vaginal purity degree:
• to insert a gynecological speculum into vagina
• to take some discharge from the posterior vaginal fornix with gynecologic forceps, spatula,
gutter sound, or Folkman's spoon and by stroking motions to drift it on a glass slide
• withdraw a speculum from vagina
• write out an order to laboratory
Laboratory assistant quantifies epithelium cells, leukocyte number, microflora character
(Doderlein's bacillus, pathogenic flora — gram-negative bacillus, cocci, fungi, trichomonades,
gonococci) and also reaction of vaginal discharge.
There are 4 stages of vaginal discharge purity.
Smear on gonorrhea presence. Material for research is taken just from the cervical canal,
urethra (before urination after light massage of the posterior urethra wall) and rectum drift on a glass
slide as separate strokes.
Bacteriological research is taken to find the pathogene and its sensitiveness to antibiotics.
Material for research is a content of cervical canal, vagina, urethra and puncture material. This
material should be sent into bacteriological laboratory. It is necessary to indicate the date and time
when the material was taken.
Oncocytologic research (Pap smear) is made for the early diagnostics of oncologic diseases.
Smear taking technique for oncocytologic research:
• speculum insertion
• carefully taking the discharge from the cervix by cotton swab which is clutched in forceps
• material for investigation is taken by gynecological disposable wooden spatula from the anterior
and lateral vaults of vagina, external cervical os, vaginal part of cervix and from pathologically
altered parts which are revealed during colposcopy. Material is taken by brush or gutter probe
(fig. 26 a, b)
• drift it on the glass slide (fig. 27)
• withdraw a speculum
• write an order to the laboratory
Cytological investigation gives a possibility to reveal women who need more detailed
examination (biopsy, diagnostic curretage, etc).
There are 5 Pap smear types:
• I type — unaltered epithelium
• II-а type — inflammatory process
• Il-b type — proliferation, metaplasia, hyperkeratosis (at corresponding clinical picture they
are interpreted as polyp, simple leukoplakia, endocervicosis
• Ill-a type — light, moderate, dysplasia on the background of benign processes on unaltered
epithelium
Fig. 26. Pap smear:

a — obtaining exocervical portion
• Ill-b type — severe dysplasia of squamous epithelium on the background of benign
processes and on unaltered epithelium
• IV type — suspicion on malignisation, intraepithelial cancer should be possible

• V type — cancer
• VI type — smear is non-informative (material has been taken in a wrong way)
Smear on "hormonal mirror". Material is taken by light touch of instrument from the upper
one-third of lateral vaults not earlier than in 2 days after cessation of any manipulations in vagina.
The taken material is thinly smeared on a glass slide. Woman's age, pregnancy term or day of
menstrual cycle is indicated.
This method can be used for diagnostics of pregnancy loss, menstrual cycle disordes and also
as a control for hormone therapy results.
Methods of functional diagnostics
Properties of cervical mucus. Properties of cervical mucus are changing due to estrogen
and progesterone action during menstrual cycle. Maximum quantity is secreted during ovulation,
the minimum is secreted before menses.
1. The mucus tension symptom. In case, when you place some mucus from cervical canal
between forceps legs and carefully move them apart, then you'll get a mucus string, the length of
which depends on the mucus viscosity. Maximum length of the string will be in ovulation period
when mucus viscosity is maximal. String's length is measured in centimeters (the greater estrogen
production the longer is the string) and is estimated for 3-point system: 1 point (+) at string length up
to 6 cm (early follicular phase), 2 point (++) — 8-10 cm (medium follicular phase, moderate
estrogen saturation), and 3 point (+++) when string length is 15 cm and more (maximum
estrogen saturation). Tension symptom diminishes and then disappears in luteal phase of
menstrual cycle.
The "pupil symptom". Cervical tone and its external os diameter are changing during menstrual
cycle under the influence of estrogen hormones. Dilatation of external cervical os and mucus
appearance in it starts from the 8-9th cycle day and up to the 14th day it is maximally dilated (up
to 3-6 mm in diameter). Mucus drop, that comes forward from external os seems to be dark and
looks like a pupil at illumination on the background of pink cervix. This is a positive "pupil"
symptom. Amount of mucus begins to decrease during the next days and up to 18th-20th day of
the cycle this symptom disappears and cervix becomes "dry". Such changes are typical for
normal menstrual cycle. In case of follicle persistence, the "pupil" symptom does not disappear up
to the time when bleeding occurs. This indicates on hyperestrogenemia and absence of luteal phase
in ovaries. The "pupil" symptom is slightly positive or absent at amenorrhea. This symptom is
also absent during pregnancy. The "pupil" symptom is estimated on the 3-point system: presence of
small dark dot means 1 point (+), early follicular phase; 2,0-2,5 mm — 2 points (++), medium
follicle phase; and 3,5 mm — 3 points (+++), ovulation. If cervix is strained by postnatal
ruptures, erosion or endocervicitis test is unreliable.
3. The "fern symptom". The "fern test" is used to distinguish the ovaries functional state. It
is named from the pattern of absorbtion that occurs when discharge is placed on a slide and is
allowed to be dried in the room air. Arborisation intensity depends on the menstrual cycle phase i.e.
on the ovarian estrogenic effect. Mucus is taken by forceps, which are inserted into cervical canal
to depth of 5 mm. Then it is drifted on a glass slide, dried up and examined under the
microscope. Such varieties of "ferm symptom" are distinguished (fig. 28 a-d) as:
Fig. 28. The «fern symptom»
a) separated leaves of the fern plant (when the quantity of estrogen secretion is the minimal)
— 1 point (+), early follicular phase;
b) expressed leaves of the fern plant — 2 points (++), medium follicle phase with moderate
estrogen secretion;
c) thick stems and leaves deviate at angle of 90° (in the period of ovulation, when more
estrogens are present) — 3 points (+++);
d) negative symptom.
This test like the previous one is used for ovulation determination. Presence of "fern symptom"
during the whole menstrual cycle indicates on high estrogen saturation (persistation of the
follicle) and absence of the luteal phase; absence of this symptom can testify about estrogen
insufficiency. Diagnostic value of all the described above tests is considerably increased in their
complex using.
Cervical index estimation
Test name Points quantity

1 2 3
0
Amount of mucus Absent Slight Moderate Considerable
Mucus tension Absent Up to 6 cm 8-10 cm 15 cm
"Pupil symptom" Absent Dark dot 2,0-2,5 mm 3,5 mm
"Fern symptom" Absent Small crystals Expressed Big leaves
and seperate leaf with thick
stems pattern stem
Cervix index or cervical number (maximum value of each point is — 3, minimum — 0
(table 1) should be determined after the summarizing of the amount of all the points received from
each test.
Cervical index up to 3 numbers indicates on the expressed estrogen insufficiency, 4-6 —
moderate estrogen insufficiency, 7-9 — sufficient estrogen saturation, 10-12 — high saturation.
Cervical index estimates presence or absence of ovulation and cyclic changes of the organism's
estrogen stimulation.
Basal temperature. Basal temperature (ВТ) changing is based on the hyperthermic influence
of progesterone on hypothalamus. ВТ is measured in rectum in the morning regularly by the
same thermometer with the empty stomach, without getting up. In first phase of menstrual cycle
temperature is below 37 °C (0,2-0,3° lower), after ovulation it rises and holds on between 37,1-
37,4 °C. Basal temperature change indicates on presence or absence of ovulation, follicle
persistence, threatened abortion and some other states. This test is simple, easily available and
sufficiently objective, however one should remember, that any causes of non-hormonal character
(diseases, that are accompanied with temperature reaction) can affect it. It is necessary to carry
out measuring during 2-3 cycles. Only in this case this method has the diagnostic value.
Cytological examination of vaginal smears
During examining degree of estrogen saturation determines the morphology of vaginal epithelium,
which is changing during menstrual cycle. Basal, parabasal, intermediate, superficial layers are
distinguished in the stratified squamous epithelium of vagina. Vaginal epithelium is exposed to
rhythmic changes during menstrual cycle, that is characterized by different stages of mucous
membrane proliferation. According to degree of organism saturation by estrogens, superficial,
intermediate and basal cells in different ratio are differed. Method of colpocyto- diagnostics is
based on the determination of quantity and morphological peculiarities of epithelial cells.1
Such indexes are determined:
• maturity index is a correlation of superficial, intermediate,

parabasal and basal 2 cells ratio, expressed in percents;
index is written in such a way: parabasal/inter- 3
mediate/superficial (parabasal and basal cells are counted
up together)
• cariopicnotic index (CPI) is a correlation of superficial
cells with picnotic nuclear and general amount of cells
ratio expressed in percents. CPI is directly proportional to
the degree of organism's estrogen , saturation
• eosinophile index — superficial cells with eosinophile Fig. 29.
cytoplasm and cells with basophilic cytoplasm ratio Squamous
expressed in percents vaginal
epithelium:
1—
superficial
2—
Cells' disposition (layers presence) and amount of the intraepithelial
3—
"rolled up" cells should be determined for revealing of progesterone effect on vaginal
epithelium. Progesterone stimulation degree is estimated for 3-point
intermediate the plenty of the
system too:
"rolled up cells" makes 3 points (+++), moderate amount makes 4 —2parabasal
points (++), low quantity
makes 1 point (+), undetermined cells makes 0 (-). 5 — basal
Assignments for Self - assessment.
II. Multiple Choice.

Choose the correct answer / statement:
1 External female genital organs include:
A –Menstrual pain ;
B - Folate-deficiency anemia;
C – Mons pubis;
2. Which of the following is Not characteristic of internal female genital organs?
A- Decreased factor VII;
B - Uterus;
C - Vagina;
D - Mons pubis.
3. Which of the following is Not characteristic of external female genital organs :
A - Vagina;
B- Hymen;
C- Labia minora;
D- Uterus;
III.Answers to the Self- Assessment. 1.C. 2.B. 3.D.
Students must know:

1 - Eexternal female genital organs.
2- Internal female genital organs.
3- Normal menstrual cycle.
4. Physical examination.
5.Methods of functional diagnostics.
Students should be able to make:

l.Plan of management of the patients with inflammatory diseases
2.Plan the treatment of the patients with inflammatory diseases .
3.Plan the delivery of the patients with inflammatory diseases .
4.Plan the postpartum care of the patients with inflammatory diseases
References:
1. Obstetrics – edited by Professor I.B. Ventskivska, Kyiv “Medicine”, 2008.
2. Gynecology – Stephan Khmil - Ternopil, 2003.
3. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994. - P. 201-225.
4. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. -1993. -- P. 406-
412.
5. Obstetrics and gynecology. - Pamela S.Miles, William F.Rayburn, J.Christopher Carey. -
Springer-Verlag New York, 1994. - P. 62-64.
4 course

FAMILY PLANNING
Topic 2. Neuroendocrine regulation. Dysfunction of the reproductive system.

I. Scientific and methodical grounds of the theme

Topicality of the theme: The menstrual cycle considered as steady biological rate of female
organism. In the female reproductive system, the menstrual cycle is a recurring cycle of
physiologic changes that occurs in reproductive age females. The menstrual cycle is under the
control of the hypothalamic-pituitary-ovarian system and is necessary for reproduction.
Menstruation disorders can be manifested by hupomenstrual syndrome and amenorrhea (lack of
bleeding or too little bleeding), hupermenstrual syndrome or dysfunctional uterine bleeding
(excessive bleeding), and dysmenorrhea (painful menstruation).
Menstruation disorders result not only in oppression of female reproductive function and
disability, but in a case of dysfunctional uterine bleeding sometimes result in a death.
As a result, the studying of menstruation disorders is actual and important in practice.
The purpose (general): to be able to diagnose various forms of menstruation disorders, to define
tactics of the patient’s management.
II. Aim:
Specific goals Initial level of knowledge and skills
To be able:
1. To choose the signs of various forms of menstruation disorders from the given complaints and
the data anamnesis.
2. To collect and estimate complaints, the life and disease anamnesis -the department of
propaedeutic therapy
- the department of propaedeutic pediatrics
- the department of obstetrics and gynecology (4 course)
3. To reveal the most informative objective signs of various forms of menstruation disorders.
4. To master the methods of physical objective inspection of women and children (examination,
palpation, percussion, auscultation). -the department of propaedeutic therapy
5. To make the scheme of diagnostic search.
6. To estimate results of laboratory tests (clinical, hormonal), rays, ultrasound
-the department of propaedeutic therapy
- the department of biochemistry
- the department of radiology
7 To make the primary diagnosis.
8. To reveal a hormonal and morphological substratum of disorders, to define the mechanism of
disease development.
- the department of biochemistry
- the department of pathological anatomy
- the department of pathological physiology
9. To define tactics of conducting the patient with menstruation disorders.
10. To represent the mechanism of action of medcine ( drugs), to define indications of blood
transfusion.
- the department of general surgery
- the department of pharmacology
Query:
- Regulation of neuroendocrine function of the reproductive system.
- Methods diagnostics of functional ovaries.
- Classification of functional disorders of the reproductive system.
- Amenorrhea: classification, diagnosis.
- Abnormal uterine bleeding. Clinic, modern methods of diagnosis and treatment
principles.
Practical skills:
- Collect special gynecological history in patient with reproductive system dysfunction;
- Gynecological examination in violation of the functions of the reproductive system;
- Evaluate tests of functional diagnostic of ovaries.
- Evaluate the results of colpocytology research
- Evaluate the results of the ultrasound examination of the reproductive system
- Make a plan examination and treatment of abnormal uterine bleeding
- Make a plan survey during amenorrhea
PHYSIOLOGY OF THE FEMALE GENITAL ORGANS

Normal menstrual cycle
Reproduction relies on a complex system of communications between the
hypothalamus, pituitary and the ovarian follicular development and ovulation. Sex steroid
hormones provides regularity of the phases of the reproductive cycle.
Normal ovulation depends on the complex and interactive hypothalamic — pituitary —
ovarian system.
There are responsible changes during the complete reproductive cycle in the target
organs: endometrium, breasts, vagina, fallopian tubes. Nervous and endocryne systems
undergo cyclic changes too.
In response to the changes, sex steroid hormones are secreted during the ovarian cycle
(follicular maturation, ovulation, development of corpus luteum). There are four main stages
of the endometrial cycle: desquamation that is menstruation, regeneration, proliferation, and
secretion phases. Due to these changes reproductive function can be perfomed: ovulation,
fertilization, implantation and emryo development. If implantation doesn't occur functional
layer of the endometrium desquamates and the menstrual bleeding begins.
Regular menstrual cycle is a sign of normal function of female reproductive system.
The rythm is genetically determinated and healthy women have it stable during
reproductive age. The first day of menstrual bleeding is considered to be the first day of the
menstrual cycle.
The modal interval when menstruation occurs is considered to be 27-29 days and may
vary from 21 till 35 days.
The duration of menstrual flow is 3-4 days (from 2 till 7 days)
The amount of blood lost is about 50-150 ml per cycle.
The menstruation must be regular, painless.
The reproductive cycle has two phases.
Regulation of menstrual cycle

The function of reproductive system is controlled by the complex of brain cortex-
hypothalamus, composed of the groups of nerve fibers and cells in which biogenic amines, steroid
hormones and gonadotropins perfom reception, translation and transmission of signals from
environment and organism. This system has 5 levels and is regulated by feedback mechanisms,
while high level structures control the lower level (fig 11,13).
Fig. 11. Regulation of menstrual cycle:

1 — uterus; 2 — fallopian tube; 3 — cervix of uterus; 4 — vagina; 5 — ovary
6, 7, 8 — different stages of ovarian development; 9 — secondary follicle
10 — ovulation; 11 — corpus luteum; 12 — effect of estradiol into uterus
13 — effect of progesterone into uterus
V-level is suprahypothalamic cerebral structures. The menstrual cycle is regulated by
brain cortex. Stress or climatic changes can cause abnormalities of ovulation and menstrual cycle.
Receiving of information from environment and interreceptions with neurotransmitter structures
of central nerves system sends impulses to neurosecretory hypothalamic nuclei.
IVlevel—hypothalamus. Hypothalamic nuclei produce the specific neurohormones, which
stimulate pituitary (called as Liberins) and inhibit it (called Statins).
Progesterone ng/ml ~~■"■■ LH mU/ml

'■
Follicular——■
Estradiol 17 pr/ml phase Ovulation LutealFSH lmU/ml
phase
—
Fig. 12. Level of hormones in female blood during by menstrual cycle
Basal temperature
Hypothalamic ventromedial, arcuate and dorsomedial nuclei produce such hormones as

Lul'iberin — releasing hormone that stimulates luteonizing hormone (LH) secretion and
Foliberin — releasing hormone that stimulates follicle-stimulating hormone (FSH) secretion by
the anterior pituitary.
Gonadotropic liberins mark as GT-RH (gonadotropic releasing hormones) because only
they stimulate the pituitary LH and FSH secretion.
The hypothalamus is the pulse generator of the reproductive clock. There is a network of
neurons in the anterior and medial parts of the hypothalamus that produces GT-RH. The drops of
this neurosecretion have been released from the ends of the brain medial eminentia neurons. GT-
RH reaches the anterior pituitary gland through the hypothalamic-pituitary portal plexus. Another
goes via veins that flow through dura mater sinuses to the general flow.
Besides GT-RH, there are hypothalamic prolactin-releasing factors and depressing substances
which contain dopamine. As hypothalamus responds tosteroid hormones secretion with estradiol
production, there is a negative feedback which has been controlled by vertebral arteries. There are
estradiol receptors in the arcuate nucleus of hypothalamus. Pulsative infusion of GnRH at 70-90-
minutes intervals depends on the level of estradiol hormones.
Ш level—anterior pituitary. Anterior pituitary produces such gonadotropin hormones
as follicular-stimulating hormone, luteinizing hormone, prolactin and other tropin hormones
such as tireotropic, somatotropic, adrenocorticotropic and lipotropic.
Basophilic cells of the peripheral areas of the anterior pituitary produce FSH. By the
chemical structure it is a glycoproteid which has been stimulating the growth and
maturation of follicles and follicular fluid secretion.
The basophilic cells of the anterior pituitary central area produce LH. It responds
massive estradiol secretion, follicular rupture, ovulation, corpus luteum formation and
progesterone production.
Prolactin is a polypeptide. It has opposite function as FSH and LH have had. It responds
to breast and target organs growth, maturation and milk secretion.
/7 level — ovaries. An ovary is a target organ for the pituitary hormones. Ovaries
respond to pituitary gonadotropin secretion. Ovarian follicles are the basic anatomo-
physiologic structure of the ovarian theca.
At birth, human ovary is filled with approximately one million primordial follicles.
Each follicle contains an oocyte that is arrested in the prophase stage of meiosis. A single
layer of pregranulosa cells surrounds the oocyte, which become the granulosa cells.
Premordial follicle is surrounded by basilar membrane that is called hematofollicular
barrier. The last one protects oocyte from the uncontrolled influence. The next stage of the
development is the transformation of premordial follicle into the primary one. It occurs as a
result of excessive reproduction of granulosa cells which contain mucopolysaccharide. The
last one forms a special brilliance membrane, which surrounds the oocyte. It is the second
protective barrier. As a primary follicle is stimulated, the pretheca cells form two layers —
internal (theca interna) which is situated near basilar membrane and secretes hormones and
external layer (theca externa). Primary follicle is transformed into antral follicle that contains
follicular antrum between the ovum and granulosa cells.
Dominant follicle is the final stage of the follicular maturation. Antral follicles can be
transformed into dominant follicles. The follicles undergo ovulation or degeneration.
At the period of puberty only 200 out of 400 000 follicles undergo maturation. Rest of them
degenerate.
During the complete reproductive cycle one oocyte is brought to maturity before ovulation. In the
process of bringing one oocyte to maturation, a number of oocytes are stimulated to partial
maturation but subsequently undergo atresia before reaching ovulation.
Ovarian cycle
An ovarian cycle consists of two phases. The first one —follicular phase, the second —
luteal phase. There is an increase of FSH, which stimulates the growth and maturation of
follicles in the first phase (fig. 14). It lasts 14 days in 28-days reproductive cycle, 10-11 days in
21-days reproductive cycle, and 17-18 days in 35-days reproductive cycle.
In the beginning of this phase follicle consists of ovum which is surrounded by the thick
membrane. It is 2-2,5 mm in diameter. An ovum increases in its sizes and has brilliante
membrane in the surface that is called zona pellucida. An ovum is packed with biochemicals that
new organism will use until its own genes begin to function. These biochemicals include proteins,
RNA, ribosomes, lipids and the molecules that influence cell specialization in the early embryo. An
ovum can be an impressive storehouse and it becomes maturate after two-cell divisions in meiosis I,
the primary oocyte is divided to form a small polar body and a large haploid secondary oocyte. In
meiosis II, reductional secondary oocyte is divided to yield another small polar body and a
mature ovum.
Polar bodies are absorbed by the woman's body and normally play no further role in the
development. Follicle granulosa membrane forms as a result of follicle cells proliferation. By that
time in the central part of these cells the cavity is formed. The last one contains follicular liquid.
Granulosa cells those form corona radiata surround an ovum. It is situated in the numerous cells
which have been situated near the follicle. This number of cells is called a cumulus oophorus. The
follicular fluid contains follicular or estrogenic hormones.
The dominant follicle reaches a diameter of 12-20 mm. As the dominant follicle enlarges
and follicular fluid accumulates in it, it grows and rupture. It is the final stage of the follicular
phase, which is called ovulation. Ovulation is the process when the membrane of mature follicle is
ruptured and oocyte is expelled from the follicle.
Oocyte gets into abdominal cavity and is taken by the uterine tube fimbrias. Process of
fertilization takes place in the uterine tubes. After ovulation the dominant follicle transform into
the corpus luteum. The second luteal phase of the reproductive cycle begins. There is
luteinization — the conversion of granulosa and theca cells to luteal cells with the acquinisation
of LH receptors. After this luteal cells can synthesize and secrete large amount of progesterone,
that is protein hormone inhibiting FSH secretion.
The corpus luteum has a fixed life term during 14 days, since 15-th to 28-th days of menstrual
cycle. There are following processes in corpus luteum: 1) vascularization 2) blossoming 3)
involution — in case when pregnancy doesn't occur corpus luteum is called corpus luteum of
menstruation. Regression of corpus luteum lasts for 2 months and is over with the formation of
white body. If oocyte becomes fertilized and implants within the endometrium, the early
pregnancy begins secreting human chorionic gonadotropin (hCG), which sustains the corpus
luteum for the following 10-12 weeks. Corpus luteum of pregnancy produces such hormone as
relaxin which has tocolytic effect on the uterus.
/ level — target organs (uterus, vagina and breasts).
Uterine cycle
The endometrial lining of the uterus undergoes dramatic histologic changes during the
reproductive cycle. There are cyclic changes in the uterus as well as in the ovaries. They are the
most considerable in the functional layer of endometrium and are composed of such phases as
desquamation, regeneration, proliferation and secretion.
Desquamation (mensis) lasts from the first to the second or fifth day of the reproductive
cycle. During menstruation, the endometrium is sloughed out both with blood.
Functional layer of the endometrium is supplied with blood by spiral arteries. The spiral arteries
extend from the arteries of the basal layer. Estrogen is a mitogenic hormone, which stimulates cell
growth. With rising estradiol production during the follicular phase of the cycle, there is growth of
the spiral arteries those extend into the surface of endometrium only at the end of the proliferative
phase. There is an excessive growth of the spiral arteries in the secretory phase. They become
most twisty and look like tangles. The capillaries those are situated in the superficial layer of
endometrium enlarge in their sizes and look like sinusoids. Spiral arteries of the functional layer
contracts before the beginning of menstruation. It causes blood stasis, thrombosis, increasing
vessel's permeability and their destroying. The necrosis and sloughing of the tissue occurs. It
finishes on the third or fourth day of the menstrual cycle.
At the same time there is an inverse development of corpus luteum in ovaries, progesterone
level decreases, hypothalamus produces foliberin and pituitary folitropin which stimulates the
maturation of the new follicle in the ovary.
Regeneration phase takes place simultaneously with desquamation and is finally completed
up to the 6-7th day of menstrual cycle. The thickness of the endometrium at this moment is 2-5
mm. There is maturing of follicle in the ovary at this time (fig. 17).
Proliferation phase lasts from the 7th to the 14th days of the cycle. The endometrium
continues to thicken and the endometrial glands continue to elongate under the estrogens influence.
The endometrium thickness is 20 mm, but its glands don't function. Endometrial glands are straight
or somewhat twisted. There is a network of argyrophile fibers inside of the endometrial strome. At
the final stage of proliferation the endometrial glands become tortuous and spiral arteries reach the
surface of endometrium (fig. 15, 18).
There is a completion of the follicle maturation in the ovary, the production of estrogens is
peak on the 14th day until the end of proliferative phase. Pituitary stops the FSH-secretion,
hypothalamus starts production of luliberin which
Fig. 15. Phase of endometrial proliferation Fig. 16. Phase of

endometrial secretion
(electronic microscopy) (electronic microscopy)
stimulates the production of LTH-in pi-

tuitary. As a result of this the level of
luteonising hormone increases.
Secretion phase. After ovulation,
the corpus luteum produces
significant amounts of progesterone,
which act on the endometrium to
increase the size of endometrial glands
and to promote the synthesis and Fig. 17. Biopsy of
secretion of proteins and other factors endometrium on Phase of
(secretory endometrium) in preparationendometrial
for pregnancy
regeneration
and implantation. This phase lasts from
the 14th until the 28th day of cycle (fig.
12).
Fig. 18. Biopsy of endometrium on

the 14th day (ovulation). Phase of
endometrial proliferation
Glandular epithelium starts to produce the secretion
containing glycopro-teids and glycogen. The signs of
secretory transformation are revealed on the 15th-18th
day. The endometrial glands become tortuous and
contain secretory material within the lumina. There is ma-
ximum amount of the secretions on the 20th-21th day of
cycle. Proteolytic and fibrinolytic activity at this time is
the highest.On the 24-27th day of the cycle (late
secretion) the endometrium is destroyed and degenerative
changes occur in it. Argyrofilic fibers destroy lacunar
distension of cappillaries and focal he-
morrhages into stroma occur. Endomet-
rium is ready to desintegration and ab-
ruptio (fig. 19). Ovarian corpus luteum
is well developed by this time. It pro-
duces progesterone, which is not a mito-
gen but causes differentiation of the
tissues containing progesterone receptors.
Progesterone converts the proliferate endometrium
into a secretory one (fig. 12). Fig. 19. Biopsy of endometrium on
the 24th day. Phase of endometrial
If fertilization and implantation don't secretion occur,
progesterone production rapidly diminishes, menstrual corpus luteum is destroyed, functional
layer of endometrium is leading to desquamation. Initiating events lead to the beginning of the
new cyclic changes in the ovaries and neuroendocrinous system in the wholefemale organism.
Some of the foreign authors have described three phases of reproductive cycle:
• proliferation (5-14-th day of cycle) which is divided into early (5-7th day) and late
proliferation
• secretion — 15-28-th day
• desquamation — 1-4-th day of the cycle
Cervical cycle
Uterine cervix is an important biological valve that controles the flow of biological
substances into the uterine cavity and from it. Besides, it protects the uterine cavity from the
infective agents' penetration. It provides menstrual blood outflow and excretion from the uterine
cavity. Endocervix is covered by a simple columnar epithelium which contains secretory crypts.
Secretory crypts produce cervical mucus. All uterine cervix structures are very sensitive to the
steroid influence. Secretory cells of the endocervix constantly produce sticky transparent liquid,
which is called cervical mucus. The quantity and composition of the mucus are regulated by the
ovarian hormones secretion and they change during the reproductive cycle. In periovulation
period the quantity of the mucus increases up to 600 mg per day, but in luteal phase the mucus
quantity is only 50 mg per day.
Hydrated gel is the main component of the mucus that contains hydrocarbo-nates and
glycoproteins. Such endocervical mucus characteristics as quantity, water contents and viscosity
are maximal at the time of ovulation when the estradiol production is increased. All these
changes create the most favourable conditions for fertilization.
Mucus flows down from the internal os to the external one. Epithelial cell microvilli
oscillations direct the mucus flow into periphery of the endocervix. It favors the movement of
active spermatocytes into the uterine cavity, which are able to overcome cervical mucus flow.
Defective spermatocytes move away from the uterine cavity.
Prostaglandines and relaxin also can influence on the uterine cervix. These hormones
promote dilation of the cervix in pre-ovulatory period.
Under the. influence of estradiol, the endocervical glands secrete large quantity of thin transparent
mucus. Pure watery endocervical mucus contains the increased number of mucin,
glycoproteides, salts and decreased quantity of cellular elements. An external os of the cervical
canal is more dilated in the ovulation; microfibrils of endocervix are situated parallely. The last
one creates the microcanals which promote the migration of spermatocytes. Under the influence
of progesterone in post-ovulatory period the cervical canal is closed, the quantity of mucus is
decreased, microfibriles are situated as network which is non permeable for spermatocytes.
Vaginal cycle
Estradiol stimulates vaginal thickening and maturation of the surface epithelial cells of the
vaginal mucous in the follicular phase. Estradiol also facilitates vaginal transudation during the
sexual excitement, creating a moist lubricated vagina for sexual intercourse. During the luteal
phase of the cycle the vaginal epithelium stops its thickness but the secretory changes are
diminished. The thickness of epithelium becomes twice less. In the result of this desquamation
occurs. The superficial layer of vaginal epithelium is desquamated in this phase.
Cellular composition of vaginal contents is a biological test of sexual glands' hormonal activity.
Superficial, intermediate, parabasal and basal cells ratio depends on the vaginal hormonal state.
The quantity of superficial cells are correlated with the estradiol saturation of organism. The
more estradiol production results in more superficial cells. During the luteal phase of the cycle the
quantity of intermediate cells predominates. Parabasal and basal cells appear during ovarian
hypofunction and menopause. They are absent during the normal ovary function in the
reproductive women.
Cyclic changes in uterine tubes

The fallopian tubes mucus has parallel folds, which are well developed in the ampulla and
become smooth in the isthmus. Folds' height and their direction depend on the ovarian estrogen
influence. They are high and parallel in the follicular phase of the cycle that makes sperms' and
ovum' migration easier. The fold surface becomes complicated in the luteal phase that blocks the
sperm movement.
Under the estrogenic influence the direction of uterine tubes cilia epithelium, fluid composition,
contractile activity are changed. The last ones create favorable nditions for fertilization.
Breast cycle
The ductal elements in the breasts, nipples and areolae respond to estradiol ;cretion. After
ovulation, progesterone stimulates the acinar (milk producing) ds. Because the acinar glands are
located in the tissue of breasts, it gives the ~ts a more rounded configuration. Moreover,
progesterone makes the venous m on the surface of the breasts and it appears more prominent and
accentuates В small Montgomery glands contained within the areolae. These dynamic changes
can be observed during the reproductive cycle.
BIOLOGICAL ACTION OF THE OVARIAN SEX STEROIDS AND
GONADOTROPINS
Estrogens
Estrogens are produced by the follicular internal membrane cells and in less quantity by the
adrenal cortex. Estradiol, estron and estriol are the main estrogenic hormones. Estradiol is the
most active. Estrogenic hormones are circulated in the blood in free state and binding together
with proteins. The last one is biological inactive form.
Cholesterol that has been created from lipoproteids is the main structural compound for all
the steroid hormones. Steroid hormone secretion is stimulated by FSH and LH and by some
enzyme systems, for example aromatases.
The quantity of estrogens predominates in blood plasma. Estrogens enter the liver, then
they go into the intestine. Estrogenic hormones are destroyed in the liver and excreted with urine
via kidneys. Uterus (endometrium and myometrium), vagina and breasts are target organs for this
group of hormones.
The main biological effects of estrogenic hormones:
• provoke the growing and development of uterus and breasts during puberty
• stimulate hypertrophy and hyperplasia of myometrium during pregnancy
• cause the proliferative phase of endometrium
• uterine-placental blood circulation regulation, increase blood supply of uterus
• stimulate vaginal mucus epithelial cells maturation and differentiation
• myometrium sensibilizing to contractile drugs, thus increasing uterine tension, excitability
and contractivity
• increase uterine tubes peristalsis during ovulation that accelerates sperm migration
• endocervical stimulation to mucus production, increase mucus plug permeability for sperm
• nitrogen, sodium and fluid retention in the organism; calcium and phosphorus retention in the
bones
• decrease the level of blood cholesterol
• reticuloendothelial system stimulation in physiologic quantities, phagocytes activity that
respond for antibacterial immunity
Thus, in general, estrogenic hormones promote fertilization, interm onse' and normal duration of
labor. Menopausal estrogenic deficiency leads to the bone's calcium and phosphorus loss,
increases quantity of cholesterol. These factors provoke bones' fractures and cardiac diseases.
Estrogenic action inti organism depends on the doses: small or average doses stimulate ovaries,
follicul lar development and maturation; large doses depress ovulation; too large dosei lead to
atrophic processes in the ovaries.
It is recommended to carry out the following problems for self-preparation and

selfcorrection of initial level of knowledge and skills.
The test 1
A 39-year-old woman consulted at the female dispensary because of profuse uterine
bleeding during the menstruation. Chronic adnexitis was in the gynecologic history.
What data of the anamnesis is it necessary to accurate in the woman?
A. Hereditary diseases
B. Respiratory diseases
C. Harmful habits
D. Occupational hazards
E. Menstrual anamnesis
The answer standard: E
The test 2
Woman complains of the pains in the low part of the abdomen which become worse
during menstrual period and sexual intercourse. Deseases of what organs is it possible
to think about?
A. Uterus
6
B. Gallbladder
C. Stomach
D. Intestines
E. Kidneys
The test 3
A 15-year-old girl with her mother are at the gynecologist reception. She complains
of the absence of menstruations. Function of what gland of internal secretion is
necessary for defining first of all?
A. Parathyroid gland.
B. Adrenal glands.
C. Ovary.
D. Thyroid gland.
E. Pancreas.
The test 4
A woman measures basal body temperature by the gynecologist recommendation.
What occurs in the first phase of normal menstrual cycle in ovary?
A. Development of a follicle
B. Corpus luteum development
C. Rupture of an immature follicle
D. Involution of a corpus luteum
E. Rupture of a mature follicle
The test 5
A 25-year-old woman has consulted the gynecologist bacause of menstruation
disorders. On bimanual vaginal investigation the dense enlarged ovaries were found
out. What special method of investigation is the best for diagnosis specification?
A. Hysterosalpingography
B. Abdominal X-ray examination
7
C. Ultrasound investigation
D. Pelvic angiography
E. Excretory urography
The test 6
The gynecologist has prescribed oral contraceptives to the patient for correction
menstruation disorders. Secretion of what hormon is inhibited by the oral
contraceptive intake?
A. Adrenocorticotropic hormone
B. Follicle-stimulating hormone
C. Somatotropic hormone
D. Prolactin
E. Progesteron
The test 7
A 49-year-old woman complains of reccurent uterin bleedings lasting for 9-12 days,
early fatigue, weakness, reduced working capacity, dizziness, syncopal states. The
decreasing number of erythrocytes and haemoglobin concentration are in the blood
analyses. What is the diagnosis?
A. General acute anaemia
B. General chronic anaemia
C. Aplastic anaemia
D. Hemolytic anaemia
E. B12-deficiency anaemia
The test 8
A woman suffers from excessive menstrual bleeding. Therapeutic and diagnostic
dilation and curettage were performed. Histological study of endometrium has
revealed the adenocystic hyperplasia of endometrium. What is the version of this
hyperplasia?
8
A. Physiological hyperplasia
B. Hormonal hyperplasia
C. Vicarious hypertrophy
D. Protective hyperplasia
E. Compensatory hypertrophy
The test 9
A 45-year-old woman with uterin bleedings has blood group II, Rh (+). Urgent
blood transfusion is nessesary. Blood group II is absent in hospital. What tactics is
correct in this case?
A. To transfuse drop blood group I, Rh (+)
B. To transfuse drop blood group I, Rh (-)
C. To refuse from the transfusion
D. To use isotonic solution of sodium chloride
E. To use isotonic solution of sodium chloride and plasma blood group II
The Academic Content
On mastering of necessary basic knowledge you have to study the graph of
logical structure of the theme.
The following theoretical questions result from the graph of logical structure of
the theme:
1. Classification of menstruation disorders.
2. The causes of menstruation disorders.
3. Primary and secondary amenorrhea (clinic and diagnostics).
4. Hormonal correction of the amenorrhea.
5. Dysfunctional uterine bleeding (clinic and diagnostics, differentials).
6. Tactics in case of dysfunctional uterine bleeding during the various age
periods of a woman’s life.
7. Dysmenorrhea (clinic, diagnostics, differentials and treatment)
9
The information necessary for the development of specific goals of training is
contained in the following materials.
4. Lecture materials
6. Site materials http://www.emedicine.com, http://www.health.am,
http://menstrualdisorders.morefocus.com.
Having studied the theoretical questions, we recommend to solve test professional
tasks for the final control.
Task № 1
A 29-year-old woman complains of the absence of menstrual bleeding for 1 year.
Breast palpation was found the expiration of milk from nipples at pressing. What
syndrome takes place at the patient?
1. Galactorrhea-amenorrhea syndrome
2. Polycystic ovary syndrome
3. Rokitansky syndrome
4. Turner syndrome
5. Hyperandrogenism
Task № 2
A 30-year-old woman complains of amenorrhea, absence of pregnancy during 3
years after marriage. The woman has obesity, growth of hair is marked on an average
line of the abdomen, on internal surfaces of hips and in peripapillary areas
(hirsutism). Menstruation since 16 years, rare and poor. On ultrasound investigation
of pelvis – uterus is not enlarged, ovaries are enlarged to 4,5×5 cm with multitude of
cyst inclusions. What syndrome does the patient have?
1. Galactorrhea-amenorrhea syndrome
3. Rokitansky syndrome
4. Turner syndrome
5. Asherman syndrome
Task № 3
A patient complains of absence of menstruations during a year. Lateral visual fields
are defect. Breast palpation found the milk expiration from the nipples at pressing.
What is most probable cause of this disease?
1. Pituitary tumour
2. Breast tumour
3. Mulfunction hypothalamic-pituitary-ovarian systems.
4. Ovarian tumour
5. Pregnancy
Task № 4
A 39-year-old woman with excessive bleeding from vagina was admitted to the
gynecologic department. The bleeding has begun after a 2-week delay of
menstruation. The test for pregnancy is negative. What will be your medical
tactics?
1. Dilatation and curettage of uterus
2. Oral contraceptives per os
3. Estradiol intramuscularly
4. Progesterone intramuscularly
5. Hysterectomy
Task № 5
A 14-year-old girl has bleeding from uterus. Her menstruations are irregular. The
decreasing number of erythrocytes and haemoglobin concentration are in the blood
analysis. What will be your medical tactics?
1. Dilatation and curettage of uterus
2. Ablation of endometrium
11
3. Oral contraceptives per os
4. Progesterone intramuscularly
5. Hysterectomy
Task № 6
A patient of 45 years old complains of the painful menstruation. Gynecology
pathology was not found out on bimanual vaginal and ultrasonic investigations.
What is your suggested diagnosis?
1. Endometriosis
2. Dysmenorrhea
4. Polyp of a uterus cavity
5. Climacteric syndrome
Task № 7
A 37-year-old woman has been complaining of profuse menstrual bleeding since
last year. Therapeutic and diagnostic dilation and curettage were performed.
Histological study of endometrium revealed the adenocystic hyperplasia of
endometrium. What is your further tactics of conducting the patient?
1. Hysterectomy
2. Ablation of endometrium
3. Appointment of steroid hormones
4. Supervision with the ultrasonic examination of a uterus every six months
5. Does not require any treatment
References:
412.
4 course

FAMILY PLANNING
TOPIC 3. NEUROENDOCRINE SYNDROMES IN GYNECOLOGY.
I. Scientific and methodical grounds of the theme: disorders of the menstrual cycle constitute
20% in the structure of gynecological diseases. Various kinds of disoderes of the menstrual
function lead to a high loss of ability to work development of neuropsychic complications,
disability of women. These complications require complex approach and combined treatment of
doctors of several specialities- gynecologists, endocrinologists, neuropathologists, etc. That’s
why,study of this pathology is of a great importance for doctors of any speciality.
II. Aim:
A student should be able to Know:
1. Regulation of neuroendocrine function of the reproductive system.
2. Methods diagnostics of functional ovaries.
3. Classification of functional disorders of the reproductive system.
4. Amenorrhea: classification, diagnosis.
5. Abnormal uterine bleeding. Clinic, modern methods of diagnosis and treatment
principles.
6. Etiology and pathogenesis of neuroendocrine syndromes.
7. Clinical signs and diagnostic methods of neuroendocrine syndromes.
8. Modern principles of treatment of neuroendocrine syndromes.

To be able to:
1. Collect general and gynecological anamnesis, perform general and gynecological examination.
2. Make up algorithms of clinical- laboratory examination to determine level of lesion in the system
hypothalamus-hypophysis-ovaries-organs-targets in case of amenorrhoae.
3. Substantiate pathogenetic treatment of primary amenorrhoea and various forms of secondary
amenorrhoea.
4. Perform differentiation diagnostics of functional and organic hyperprolactinemia.
5. Prescribe treatment of hyperprolactinemia.
6. Perform differentiation diagnostics of uterine bleeding connected with disorders of hormonal
function of the ovaries, interruption of pregnancy and malignant diseases of the uterine.
7. Make diagnosis of disorders of the menstrual cycle.
8. Substantiate pathogenetic and symptomatic treatment of various kinds of DUB.
9. Prescribe medicines for hormonal hemostasis depending on age of the patient.
3.3. Practical rules:
1. To know the main etiological and pathgenetic reasons of disorders of the

menstrual cycle.
2. To classify and analyze the typical clinical picture of disorders of the menstrual
cycle.
3. To make the plan of inspection and make analyses of the data of laboratory and instrumenta
research of disorders of the menstrual cycle.
4. To find the tactic of treatment of disorders of the menstrual cycle.
.4. Basic knowledge.
Name of the course Received skills

Human anatomy To know the structure of the female reproductive organs
Biochemistry To know the steroidgenesis
Hystology To know the structure of reproductive cells, endometrium,
ovaries, uterus and uterine tubes
Normal and pathological Interpretation the data of hormonal function of the female
physiology reproductive system, hormonal changes
Internal deseaeses Collection the anamnesis, to make the physical
inspection, to see the clinical symptoms and syndromes,
to find methods of diagnostic, estimate the results of
paraclinic
References:
412.
Methodological gydelance was made by assistant professor of obstetrics and gynecology

department Loskutova T.O.
4 course

FAMILY PLANNING
TOPIC 4. BENIGN TUMORS OF THE FEMALE GENITAL ORGANS.

ENDOMETRIOSIS.

Recently the problem of endometriosis has become especially actual due to the increase of
frequency of this pathology, implementation of modern diagnostic and therapeutic methods in to
practice that’s why the aim of the practical lecture is the study of etiopathogenesis of
endometriosis, methods of its diagnostic and treatment
II. Aim:
A student must know:
1. Classification of endometriosis of female genitalia .
2. Main clinic symptoms for endometriosis of female genitalia.
3. Methods of diagnosis of endometriosis of female genitalia.
4. Main principles of therapy of endometriosis of female genitalia.
5. Indications for surgery of endometriosis of female genitalia.
6. Possible developmental anomalies of uterine tubes, ovaries.
7. Clinic, diagnosis and treatment infantilism.
1. Collect general and specific gynecologic anamnesis.
2. Make up a plan of examination and treatment of endometriosis.
ENDOMETRIOSIS
Endometriosis involves deposits of endometrium outside the uterine cavity. Its
manifestations are very variable and often bear no relation to the extent of the disease.
Pathology
The gross appearance shows ectopic deposits which can very in number from a few in one
locality to large numbers distributed over the pelvic organs and peritoneum.
The commonest sites of these deposits are:
The commonest appearance of a typical lesion is that of a round protruding vesicle which shows
a succession of colours from blue to black to brown. The variation in colour is due to
haemorrhage with subsequent breakdown of the haemoglobin. Ultimately the area of
haemorrhage heals by the formation of scar tissue. The result is a puckered area on the
peritoneum. Commonly however the haemorrhage results in adhesion to surrounding structures.
These adhesions are more apt to form between fixed structures such as the broad ligament,
ovary, sigmoid colon or the posterior surfaces of the vagina and cervix.
The ectopic deposits of endometrial tissue vary in size from pin-point to 5 mm or more. It
is these larger deposits which tend to rupture leading to adhesions. These adhesions over the
ovary can lead to the formation of quite large haemorrhagic cysts due to continued bleeding from
deposits, the blood being unable to escape. Investigation has shown that many lesions do not
have a 'typical' appearance. The following is a list of other appearances which have been
described. White, slightly raised opacities due to retro-peritoneal deposits. Red flame-like or
vascular swellings, more common in the broad ligament or utero-sacral ligament. Small
excrescences like the surface of normal endometrium.
Adhesions under the ovary or between the ovary and the ovarian fossa peritoneum. Cafe-
au-lait patches often in the Pouch of Douglas, broad ligament or peritoneal surface of the
bladder. Peritoneal defects on utero-sacral ligament or broad ligament. Areas of petechiae or
hypervascularisation usually on the bladder and the broad ligament.
Secondary pathology
This is due to the adhesions between the endometriotic deposits and adjacent organs. In long-
standing cases the pelvic cavity is obliterated by these adhesions. Retroversion of the uterus can
be produced.
Clinical findings
The incidence of endometriosis has been estimated at 3 to 7% of women but the true incidence
is unknown. Quite often deposits are found incidentally in women who have no symptoms of
endometriosis and are undergoing laparoscopy or laparotomy for some other condition. In
addition, as indicated in the section on pathology, many peritoneal changes now known to be due
to endometriosis were undiagnosed in the past.
The prevalence of endometriosis peaks between the ages of 30 and 45 years. Since ectopic
endometrium is stimulated by the same ovarian steroid hormones as the endometrium lining the
uterine cavity, endometriosis is almost never found outside the reproductive years.
Symptomatology
A. Pain affects more than 80% of women with endometriotic deposits. The pain tends to
begin premenstrually reaching a peak during menstruation and subsiding slowly.
The character of pain may vary as does its apparent origin. It may be generalised
throughout the abdomen and pelvis like the pain of severe dysmenorrhoea. Alternatively, pain
may be localised to a particular site within the pelvis. Deep dyspareunia affects around 40% of
women with endometriosis.
B. Menstrual disturbance. Menstrual disturbance affects around 20% of women with
endometriosis. It may take the form of premenstrual 'spotting', menorrhagia or infrequent
periods. Lesions in the wall of the bladder may result in 'menstrual haematuria'.
C. Infertility. Endometriosis is found more commonly in women undergoing investigation
for infertility than in the 'normal' population. It is not clear which condition arises first.
Approximately 30% of patients with endometriosis complain of infertility. When endometriosis
is extensive, and both fallopian tubes are occluded, the mechanism by which endometriosis
prevents conception is obvious. However, milder forms of endometriosis are also associated with
subfertility, and here the pathophysiology is less clear. The most likely mechanism appears to be
that immunological factors within the peritoneal cavity inhibit normal gamete function, thus
reducing fertilisation rates.
Physical examination
Endometriosis cannot be diagnosed by physical examination alone. However, enlargement of
the ovaries, fixed retroversion of the uterus and tender nodules within the pelvis may each raise
the suspicion of the disease. Endometriosis should always be considered when patients have
symptoms referable to the pelvic cavity.
Laparoscopy
Laparoscopic examination is the only way of making a positive diagnosis. The lesions can be
seen and their number and location estimated. Endometriosis of long standing may be very
difficult to diagnose due to obliteration of the pelvic cavity by adhesions. Histological
confirmation must be obtained if feasible.
Imaging techniques
Ultrasound, computerised tomography and magnetic resonance imaging may suggest the
presence of endometriosis (e.g. by the demonstration of a particular type of ovarian cyst) but are
by themselves insufficiently reliable to make the diagnosis.
Differential diagnosis
Due to the mixture of symptoms and the variation in appearance of the pelvic structures,
conditions such as pelvic inflammatory disease and tumours of the ovary and bowel must be
considered and eliminated.
Histogenesis. There are three theories.
Retrograde spill of menstrual debris through the tubes. Retrograde menstruation takes
place in most women, but it is unclear why some women should develop endometriosis while
others are unaffected.
Metaplasia of embryonic cells. These are derived from the primitive coelom and may
remain in and around the pelvis and differentiate into Mullerian duct tissue.
Emboli of endometrial tissue may travel by lymphatics or blood vessels and become
established in various sites.
The first of these theories is most favoured.
TREATMENT. Medical treatment. Any treatment must be aimed at treating symptoms.
Since ovarian hormones are responsible for growth and activity in endometrium many medical
therapies are designed to reduce ovarian steroid production or oppose their action.
1. Progestogens
Progestogens in a relatively high dose (e.g. medroxyprogesterone acetate 10 mg tid) induce
decidualisation, and sometimes resorption of ectopic endometrium. Side effects include weight
gain, bloating and irregular vaginal bleeding.
2. Combined contraceptive pill
The combined oral contraceptive pill also induces decidualisation of ectopic endometrium.
It may be given continuously for up to 3 months.
3. Danazol
Danazol is a steroid hormone closely related to testosterone, which inhibits pituitary
gonadotrophins, is anti-oestrogenic, anti-progestational, slightly androgenic and anabolic. The
dose of danazol given can be titrated to the patient's symptoms up to a maximum of 800 mg
daily. If danazol can be tolerated, symptoms and objective signs of disease can be alleviated in
the majority of patients. However, androgenic side effects including amenorrhoea, weight gain,
acne, hirsutism and deepening of the voice may limit acceptability of the drug.
4. Gestrinone
Gestrinone is a derivative of 19-nortestosterone. It has slight androgenic activity and is
markedly anti-oestrogenic and anti-progestogenic. It interacts with the pituitary steroid receptors
and decreases gonadotrophic secretion resulting in diminished follicular growth and anovulation.
A bi-weekly oral dose of 2.5 to 5.0mg for 6 months induces amenorrhoea, disappearance of pain
and regression of the endometrial deposits. Side effects include weight gain, acne, seborrhoea
and mild hirsutism.
Gonadotrophic releasing hormone analogues (GnRH analogue)
GnRH analogues are administered by depot injection or nasal spray. Their mode of action is
shown above. Although these drugs are generally effective in treating symptoms, menopausal
side effects, in particular bone loss, may preclude long term use. In the future, use of 'add back'
regimens which include small supplementary doses of oestrogen may prove to be effective in
treating the symptoms of endometriosis without the complications of total oestrogen deprivation.
Conclusion
As with medical therapies for other conditions, the optimum treatment is dictated by the
side effect profile which is most acceptable to the patient. None of the drug treatments described
will prevent recurrence of endometriosis once therapy has been stopped, although there may be a
period of some months between stopping treatment and the re-emergence of symptoms. No
medical treatment has been shown to improve subsequent fertility. Notwithstanding, none of the
above, with the exception of the combined pill, is a proper contraceptive agent and patients
should be advised to use barrier contraception to avoid the potential teratogenic effects of drugs
such as danazol if they are at risk" of becoming pregnant.
Surgical treatment
Where infertility is not a problem radical surgery to remove both ovaries is said to be a
lasting cure for endometriosis, since it removes the oestrogenic stimulus to endometrial growth.
In many cases the patient wishes relief from pain but also desires to retain the possibility of
future pregnancy. In these circumstances only conservative surgery can be employed.
The intentions in conservative surgery are:
 To ablate as many endometrial deposits in the pelvic cavity as possible.
 To restructure the pelvic anatomy by destroying adhesions which interfere with ovarian
and tubal function.
 To destroy endometrial deposits in the ovaries.
 To deal with sensory nerve pathways.
In view of the many vital structures such as the bladder, rectum, colon and ureters in close
proximity to each other, conventional open surgery is not always feasible. Laser surgery under
laparoscopy, with its almost microscopic accuracy, may be employed. Endometrial deposits and
adhesions can be vaporised easily without damaging tissue outside a radius of a fraction of a
millimetre from the target. Similarly the laser destruction of ovarian lesions can be carried out
without destroying any of the functional tissue.
The question of dealing with sensory nerve pathways is difficult to answer. Severe pain is a
feature of a number of gynaecological conditions, especially those related to malignancy.
Elsewhere in this book operative techniques are described which involve interfering with sensory
conductivity centrally, i.e. at the spinal cord level. Recently, a local operative procedure,
paracervical uterine denervation, has been recommended. This consists of vaporising the utero-
sacral ligaments by laser at their attachment to the posterior aspect of the cervix where the
sensory fibres emerge from the uterus. Two difficulties are associated with this procedure. First,
the ureters must be avoided and, secondly, veins lying lateral to the ligaments must not be
injured. Unfortunately severe pain is often associated with severe endometriosis and adhesions
may make the operation very difficult.
Reports in the literature record complete relief from pain in 50% of patients followed for
more than a year and another 41% obtained moderate relief.
IV. Control questions and tasks
1. Frequency of endometriosis pathology.
2. Classification of endometriosis.
3. Laboratory methods of endometriosis diagnosis.
4. Conservative methods of treatment.
5. Surgical methods of treatment.
V. List of recommended literature
412.

4 course

FAMILY PLANNING
TOPIC 5. BACKGROUND AND PRECANCEROUS DISEASES OF FEMALE

GENITALS. MALIGNANT DESEASES. TROPHOBLASTIC DISEASES.
1. Topicality: Early and active detection of benign tumours and precancer disorders of the female
reproductive organs and mammary glands, their timely and correct treatment –are the guarantee
to solve the problem of malignant diseases. Annumerated causes make this topic rather
important.
2. Educational objectives: to acquaint the students with frequency, structure, risk factors of
development of benign formations of the female reproductive organs and mammary gland.
Discuss clinical manifestation, methods of diagnostics and treatment of benign tumours of the
external genitals, ovaries, uterus and mammary gland.
3. 3.1 To know:
1. Pathogenetical variants of development of uterine myoma.
2. Classification of uterine myoma.
3. The main clinical symptoms peculiar for uterine fibromyoma.
4. Examination methods to diagnose uterine myoma.
5. Conservative methods of treatment.
6. Indications for surgical treatment of myoma.
7. Methods of surgical treatment of myoma.
8. Classification of benign ovarian tumours.
9. Complications of ovarian tumours.
10. Peculiarities of examination and treatment of ovarian cystoma.
11. Gynecological preconditions of diseases of the mammary gland.
3.2 To be able to:
1. Diagnose benign tumours of the external genitals, uterine and adnexa.
2. Make up a proper plan of examination to diagnose benign uterine tumours.
3. Make up a proper plan of examination to diagnose benign ovarian tumours.
4. Prepare a set of instruments to perform diagnostic scrapping of the uterine wall.
5. Make a target biopsy of the uterine cervix.
6. Perform speculum examination, vaginal examination, make the initial diagnostics.
8. Make up an individual plan of treatment.
3.3 Master the practical skills = a III.
1. Speculum examination of the uterine cervix.
2. Take smears for the cytological examination.
3. Bimanual gynecological examination.
4. Perform differentation diagnostics of intramural band submucous uterine myoma, cyst and
cystoma.
5. Determine indications for surgical treatment in patients with ovarian tumours and their
complications (torture of tumour peduncle, rupture and malignization).

BENIGN OVARIAN TUMORS
Ovarian tumors are very common among all gynecologic diseases The mortality rate is high
because no effective screening devices are available for early detection.
According to pathogenic theory of ovarian tumors, gonadotropic ovarian hyperstimulation is the
leading factor in the development of ovarian tumors. This theory should be recommended for
pathogenetical explainatum of malignant ovarian tumors diagnosis and treatment.
The risk factors associated with ovarian carcinoma are:
 women with impairment of ovarian function
 women with postmenopausal bleeding
 women that have been monitored for a long period of time with the diagnosis of uterine
fibromyoma, chronic inflammatory processes of uterine adnexa, benign ovarian tumors
 women that have had surgical intervention in pre- or postmenopause with keeping ovaries (or
their resection)
All ovarian tumors should be divided into two main groups:
 blastomatic unprohferative tumors (ovarian cysts)
 blastomatic proliferative tumors (ovarian cystadenomas)
Clinical manifestations of ovarian tumors are various and usually uncertain. It depends on
tumor's type and character, and also on the spread of the process in the case of malignant tumor.
OVARIAN TUMORS CLASSIFICATION
Only histologic signs can give a possibility to distinguish benign and malignant ovarian tumor.
From the prognostic or survival standpoint, however tumor grade remains the most important
factor for all the ovarian tumors.
Histologic classification of ovarian tumors is presented below.
I. Epithelial tumors:
A. Serous
B. Mucinous
C. Endometriod
D.Clear cell
E. Brenner
F. Mixed epithelial
G.Undifferentiated
H. Unclassified.
There are benign and malignant tumors in each of these groups of neoplasms.
II. Sex cord stromal tumors:
A. Granulosastromal cell
B. Androblastoma
C. Gynandroblastoma
D. Unclassified
III. Lipid cell tumors
IV. Germ cell tumors:
A. Dysgerminoma
B. Endodermal sinus tumor
C. Embryonal carcinoma
D. Polyembryoma
E. Choriocarcinoma
F. Teratoma
G. Mixed forms
V. Gonadoblastoma:
A. Only blastoma (without any forms);
B. Mixed with disgerminoma and other forms of germ cell tumors.
VI. Soft tissue tumors not specific to the ovary.
VII. Unclassified tumors.
VIII. Secondary (metabolic) tumors.
VIII. Tumor-like conditions:
A. Pregnancy luteoma
B. Ovarian stroma hyperplasia and hyperkeratosis
C. Considerable ovarian edema
D. Functional follicle cyst and luteal cyst
E. Multiple luteal follicle cysts and (or) luteal cysts
F. Endometriosis
G. Superficial epithelial cysts-inclusions
H. Simple cysts
I. Inflammatory processes
J. Paraovarian cysts
UNBLASTOMATIC UNPROLIFERATIVE OVARIAN TUMORS (ovarian cysts)
Follicle cyst
Follicle ovarian cyst is a single tumor with a thin membrane of mobile consistency with a
straw-colored fluid. Its formation is a result of fluid retention in atretic follicles. Follicle cyst
may be found in women of any age more often after inflammatory processes. True ovarian
blastopmatic process is absent in such tumor. Cyst membrane is not a new created tissue, it’s a
result of the excessive extension of follicle membrane. Although these cysts may attain a size
from 8 to 10 cm in diameter, spontaneous resolution usually occurs within the weeks. It has been
growing inside of abdominal cavity.
Clinic. The main symptom is the low abdominal pain, rarely menstrual cycle impairment or
uterine bleeding as a result of hyperstimulation from exogenous gonadotropins is observed.
Signs of acute abdomen are present in the case of ovarian cyst torsion. Bimanual examination
reveals ovarian enlargement up to 10 cm. It is mobile, cystic unilateral mass. Sometimes
inflammatory processes in uterine adnexa are present. Follicle cysts rarely produce any
symptoms and diagnosis is often made during monitoring.
Tratment. Observation for 2-3 menstrual cycles is necessary. If a spontaneous resolution doesn’t
occur, surgical intervention-ovarian resection or oophorectomy – should be recommended. It is
very necessary because before surgical intervention it is difficult to make a differential diagnosis
of ovarian cyst and serous cystadenoma. Total hysterectomy should be performed in climacteric
and postmenopausal women.
Corpus luteum cyst
Corpus luteum cyst is an unilateral cyclic enlargement which exceeds 8 cm in diameter. Grossly,
the cyst protrudes from the contour of the ovary and the wall appears convoluted and thick. The
cyst is filled with yellow fluid or blood.
Clinic. Symptoms are related to large size or complications of torsion, rupture or hemorrhage.
The main complaint of the patient is abdominal pain as a result of concomitant inflammatory
processes of uterine adnexa. Special clinical signs are absent. Treatment More commonly
luteum cysts produce no symptoms and undergo absorption or regression. It is necessary to make
observation for 2-3 reproductive cycles. Surgical intervention should be recommended in the
case if corpus luteum cyst regression doesn't occur.
Theca lutein cysts belong to retential ovarian cysts.
Parovarian cyst. Parovarian cyst is formed as a result of fluid retention in ovarian adnexa which
has been situated in the broad ligament. It arises at the age of 20-40 years old because only in
reproductive period ovarian epoephoron is well developed and it undergoes atrophic changes in
climacteric women.
Clinic. Pain in the lower abdomen and sacral region may be present. Symptoms of adjacent
organs compression are present if the tumor reaches large sizes. Symptoms of acute abdomen are
common in the case of parovarian pedicle cyst torsion. At bimanual examination pelvic mass
with smooth surface and elastic consistency which is palpated near uterus is found. It is painless
and immobile.
Treatment. Surgical removal of parovarian cyst. It is very necessary to store the ovarian
function. Puncture of the cyst should be indicated in some cases.
BLASTOMATIC PROLIFERATIVE OVARIAN TUMORS
(ovarian cystadenomas)
Serous cystadenoma. Serous cystadenoma is unilocular unilateral benign cystic neoplasm
derived from the surface epithelium of the ovary and lined by epithelium that resembles the
mucosa of the oviduct. It contains clear yellow fluid. The benign serous cystadenoma is usually
between 5-15 cm in diameter. The symptoms of peritoneal irritation are present in the case of
pedicle torsion. These tumors are revealed during monitoring.
Pelvic examination reveals mobile, painless and unilateral tumor with smooth external surface.
Ultrasonography and laparoscopy may confirm the diagnosis.
Treatment is surgical because of the relatively high rate of malignancy. In the patients after the
childbearing age (after 40 years old) treatment should consist of bilateral salpingoophorectomy
and hysterectomy not only because of chance of future malignancy, but because of the increased
risk of similar occurrence in the contralateral ovary. In the younger patients with smaller tumors
an attempt can be made to perform an ovarian cystectomy to try to minimize the amount of
ovarian tissue removed.
Papillary serous cystadenomas. The papillary projections of ovarian cystadenomas may grow
inside and outside of the tumor capsule. There are also mixed tumors when these projections are
placed into internal and external surfaces of the tumor. No characteristic symptoms are specific
for this tumor. Frequently, it is revealed during monitoring. The diagnosis is based on the results
of bimanual examination, ultrasonography and laparoscopy.
Bimanual examination reveals immobile painless lobulated tumor which is situated near uterus.
Frequently it resembles the subserosal uterine fibroid. These tumors have high frequency of
malignant change.
Treatment is surgical and it is the same as in case of serous cystadenomas.
Mucinous cystadenoma
Mucinous cystadenoma is a benign epithelial tumor which may be present in women of different
age. It may reach large sizes, sometimes it is multilocular, with round or oval form. The cut
surface shows the individual cysts or lobules of various sizes that contain sticky slimy or viscid
material of yellow or brown color.
Clinic. No symptoms are specific for this tumor even in case of large sizes Pain in the lower part
of the abdomen and back region may be present in case of intraligamentous location. Symptoms
of adjacent organs compression are present if a tumor is huge. Ascites is rare. Bimanual research
reveals elastic tumor with lobular surface in the adnexal region. Laparoscopy and
ultrasonography can be used for diagnostics.
The usual treatment for the obviously benign mucinous cystadenoma is unilateral
oophorectomy.
Pseudomyxoma. Pseudomyxoma is one of the kinds of mucinous cystadenoma. The incidence
of these tumors is low. The tumor is multilocular and has a thm wall It can be ruptured
spontaneously or during the pelvic exam. Pseudomyxoma peritoneal is the complication that may
result if the contents of mucinous cyst is spilled into the peritoneal cavity by rupture, extension
or at surgery.
Clinic. Pain is the main characteristic sign of pseudomyxoma The clinical course is usually
progressive malnutrition and emaciation. The palpation of the abdomen is painful.
Pelvic exam reveals elastic tumor, frequently of large sizes which is situated near uterus The
diagnosis is proved during operation.
Treatment is surgical. The fluid is difficult to remove because of its viscosity. Repeated
chemotherapy may be required in postoperative period
Cystadenofibroma. Cystadenofibroma is a benign tumor which is developed from ovarian
stroma. It has round or oval form, it is firm and unilateral and may reach the sizes of fetal head.
The age distribution is 40-50 years old It has asymptomatic duration or sometimes it is
accompanied by ascitis. Hydrothorax and anemia may be present in rare cases (Meigs Syndrome)
The treatment is surgical — removal of the tumor.
SPECIAL FORMS OF OVARIAN TUMORS
Androblastoma (arrhenoblastoma). Androblastoma which is usually masculinizing tumor is
reported to produce masculinization. It occurs very rarely and its duration is also malignant.
Androblastoma is unilateral tumor with smooth or lobular surface. It has small sizes and pedicle
and it is mobile.
Clinic. Breast, uterine and female external genitalia atrophy are the characteristic signs. Uterine
and ovarian hyporplasia, endometrial atrophy are common. Amenorrhea and all masculinizing
features are present. The combination of masculinizing and feminizing symptoms is possible.
Diagnosis. Ultrasonography, laparoscopy and ovarian biopsy play an important role at
confirmation of diagnosis.
Treatment is surgical — removal of the tumor.
In the majority of cases prognosis is favorable.
Thecoma (Theca cell tumor). Thecoma belongs to the feminizing tumors. It occurs at all ages
but is common after 40 years old and later. The evidence indicates that thecomas arise from the
ovarian cortical stroma. Theca cell tumors are unilateral and in most cases they are not
malignant. Their sizes may vary from small to those of fetal head. The external surface is firm,
ovoid or round, smooth, and gray, occasionally streaked with yellow. Symptoms are related to
estrogen production. When the granulosa cell tumor occurs in the pediatric age group, it may
contribute to signs and symptoms of precocious puberty and vaginal bleeding. In women of
reproductive age group such symptoms as impairment of menstrual function, infertility and
pregnancy loss are common. Menopause bleeding, enlarged sizes of uterus and breasts,
increasing libido are present in these patients.
Diagnosis is based on clinic, bimanual research, ultrasonography, laparoscopy and hysteroscopy.
Treatment is surgical.
Folliculoma. Folliculoma is a hormonal active tumor which produces estrogenic components
and may be manifested in patients through feminizing characteristics. It varies from microscopic
inclusions to 40-50 cm in diameters, they are yellow-colored.
Clinic. Symptoms depend on the level of hyperestrogenemia and on the women age. The girls
have the signs of precocious puberty. In reproductive age group women amenorrhea, acyclic
bleeding, and later menopausal uterine bleeding may be present.
Diagnosis is based on the ultrasonography results, laparoscopy, histologic examination of tissue.
Treatment is surgical In malignant duration of the disease total hysterectomy with omentum
major incision should be performed. Chemotherapy is prescribed in III-IV stages of cancer.
Benign cystic teratoma (Dermoid cyst)
Dermoid cysts are almost always ovarian tumors. The tumors may occur at any age Dermoids are
bilateral and have 5-10 cm in diameter. At operation, the tumors are found to be round with
smooth, glistening, grey surface. At body temperature, they have the consistency of other tensely
cystic tumors. Outside the body, they have a soft pultaceous consistency.
Clinic. No symptoms are common for small sizes tumors. Pain is present in case of large tumors.
Ultrasonography, laparoscopy are used for diagnosis.
Treatment is surgical. It consists of excision of the cyst, conserving the remaining portion of the
ovary.
Brenner tumor.
The Brenner tumor is a fibroepithelial tumor with gross characteristics similar to those of
fibroma. It constitutes approximately l%-2% of all the ovarian tumors and is rarely malignant.
Brenner tumors have been reported in patients older than 50. Frequently a tumor is unilateral, its
shape, sizes and consistency are similar to fibroma.
Clinic. A few Brenner tumors are associated with postmenopausal bleeding, and it is suggested
that some may contain hormonally active stroma. Bimanual examination, ultrasonography and
laparoscopy are diagnostics.
Treatment consists in simple excision or oophorectomy.
Diagnosis of benign ovarian tumors.
General and pelvic examination should be performed. Differential diagnosis should be made
with uterine fibromyoma, endometriosis, inflammatory tuboovarian tumors and moving kidney.
Additional methods of investigation such as uterine probbing, culdoscopy, cystoscopy,
urography, X-ray examination, ultrasonography and laparoscopy should be performed.
Thus, benign ovarian tumors have some common peculiarities of clinical course, such as:
 for a long period of time they are asymptomatic, they are growing into direction of abdominal
cavity. Pain is a common symptom in case when the tumor is growing intraligamentously
 in the majority of cases cysts and cystadenomas are mobile as a result of pedicle presence. The
anatomical and surgical pedicles are distinguished. The anatomical pedicle is composed of the
infundibulopelvic ligament, the ovarian ligament and mesoovarium. Surgical ligament composes
of all of these structures and fallopian tube with its nerves vessels. During tumor removal the
clamps should be put on the surgical pedicle below the place of torsion
 the signs of adjacent organs compression are present during tumor' growing
 the tumors are palpated as a rule in the lateral sides of the uterus
UTERINE MYOMA
Uterine myoma (fibromyoma, leiomyoma) — is a benign tumor which contains varying amounts
of muscle and fibrous elements.
Concerning gynecologic diseases benign tumors are found in 10-25% of all the cases, although
during the last years the tendency of increasing the quantity of these tumors is observed. The
myoma arises seldom in young women. The risk of disease grows after 35-40 years, at the age
which is close to climacterium. Later beginning of menstrual function, irregular menstrual cycle,
high frequency of induced abortions are present in the past history of the patients. Therefore, 35-
40 years women are patients at risk for uterine fibromyoma.
Tumor histogenesis and structure. Uterine myoma belongs to tumors, which are growing from
mesenchyma. It has three consecutive stages in its morphogenesis. They are:
 active region of growth formation
 growing of tumor without differentiation
 growing of tumor with differentiation and maturation
The areas of growth are formed mainly around the vessels. These regions are characterized by a
high level of metabolism and increased capilary and tissual permeability which stimulate the
tumor growing. Uterine fibroid has in its development parenchymal-stromal features of that
layer, from which it has been educed, therefore the parenchyma and stroma ratio in a tumor is
different. Leiomyoma is developed at predominance of muscle elements, in the structure of
fibromyoma fibrous tissue is predominant. The consistency of tumor depends on fibrous and
muscle tissue ratio: the more there are muscle fibers, the more the tumor is mild at palpation.
Myomas are classified according to histologic structure as myoma, fibromyoma, angiomyoma
and adenomyoma. According to the speed of growing there are the tumors which are growing
slowly and quickly. According to histogenesis peculiarities there are distinguished simple and
proliferative myomas. Proliferative myomas contain much more atypical muscle elements, where
is a great number of plasmatic and lymphoid cells and increased mitotic activity. The incidence
of proliferative myomas happen twice more often in the patients with fast growing tumors.
Very often uterine fibroids arise in places of complex interlacing of muscle fibers of uterus —
near tubal angles, on uterine center line. The myoma is characterized by the effusive growing. As
compared with cancer fibroids they move apart tissue without destroying it. Tumor is growing
simultaneously with tissue mass surrounding it. Uterine fibroids have few veins, basic amount of
vessels is situated in pseudo-capsule. Uterine fibroids' lymphatic system is atypical without
absorbent vessels. Uterine fibroids are deprived of nervous terminals, choline and adrenergic
nervous frames.
According to their location in the uterus myomas are classified into:
 subserosal — subperitoneal uterine fibroids, which are growing under the outer serosal layer of
the uterus, may have a wide or thin pedicle.
 interstitial (intramural, intraparietal) — uterine fibroids, which are growing within the muscular
wall of the uterus
 submucosal — uterine fibroids which are growing under the uterine mucous into the uterine
cavity
 atypical forms of uterine fibroids location: retrocervical myoma grows from the posterior surface
of the uterine cervix, it is situated within a retrocervical fat; paracervical myoma grows from the
lateral part of uterine cervix, it is situated in the paracervical fat; intraligamentary myoma grows
from the uterine body or cervix within the broad ligaments.
The fibromyoma can have one fibroid (nodulosus fibromyoma), many fibroids (multiple
fibromyoma) and diffuse growth (diffuse fibromyoma).
Hormonal status of the patients with fibromyoma. They are considered hormonally depend
tumors because the growth of these tumors is related to estrogen production. In the majority of
cases these patients have an hormonal dysfunction of ovaries which is characterised by
anovulatory cycles, corpus luteum insufficiency. It leads to hyperestrogenemia and lowering of
progesterone level. Small cystic changes in ovaries occur due to hormonal disordes. Uterine
endometrium and myometrium are under the influence of estrogenic hormones. Their excessive
amount in blood can lead to endometrial hyperplastic processes and cystic changes in
myometrium. Such local hyperhormonemia leads to pathological hypertrophy of myometrium.
Not only sexual hormones synthesis, metabolism and interaction impairment, but also the state of
the myometrial receptors especially large activity of the estrogen receptors as compared with
progesterones receptors, take part in a pathogenesis of uterine fibromyoma.
Fibromyoma grows slowly without any proliferative changes at presence of small cystic changes
in ovaries with nonsignificant hyperestrogenemia. Fibromyoma growing depends on its type,
location, blood supply and patient's age. Fibromyoma grows quickly in young patients,
particularly during pregnancy, as the fetoplacental complex synthesizes large amount of
estrogenic hormones, which are tumor stimulating growing factor. Quite often fibromyoma
accelerates its growing in climacterium, when there is a rearrangement of woman's hormonal
system. Ovaries undergo polycystic degeneration at that time.
Clinic. Clinical manifestation of fibromyomas depends on uterine fibroid's location, size of
tumour, rate of its growing, and also presence of complications.
Of the most myomas there are not any symptoms at the initial stages. The main symptoms are
pain, bleeding, sensation of pelvic heaviness in the lower part of the abdomen, progressive
increase in pelvic pressure, infertility, frequent urination, pressure on the rectum. These
symptoms most commonly occur during the excessive growth of tumor, and sometimes they
testify development of secondary degenerative or inflammatory changes in fibromyoma tissue.
Menstrual function in the patients does not variate in case if tumor is sub-serosal because
attached to the uterus by only a stalk or on a wide basis under a peritoneal integument and it is
practically outside of uterine borders. Another spectrum presentation includes patients with
atypical (subperitoneal) location of uterine fibroids: the tumors from the anterior wall of the
uterus and antecervical location can press upon urinary bladder and cause dysuric signs;
pressure on the ureters (as they traverse the pelvic brim) leads to hydroureter and sometimes to
hydronephrosis. Retrocervical location of uterine fibroid due to intensive growing can spread in
all small pelvic, compressing rectum and provoking constipation.
Intraligamentary tumor during its growing moves apart the broad ligament of the uterus. As the
ureters are passing in the lower areas of parametrium, the tumor results in pressure upon ureters
leading to hydroureters or hydronephrosis.
Cyclic menstruation is present but it is painful (algomenorrhea).
Submucosal location of uterine fibroid is characterized by cramping cyclic menorrhagia which
has been changed into acyclic bleeding.
Monthly appreciable bleeding leads to the secondary iron deficiency anemia.
Characteristic dystrophical myocardial changes called "myom' heart" result from the secondary
anemia and chronic hypoxia and are often found in patients with fibromyoma. Liver function is
frequently broken in these patients. Probably, these changes are the result of steroid hormones
metabolism dysfunction. Hypertrophy of the left ventricle, myocardial dystrophy, ischemic heart
disease, idiopathic arterial hypertension are also present in these patients. In most of the patients
after fibromyoma removal the arterial pressure is reduced to the normal level. This fact confirms
the idea of pathogenetic connection of fibromyoma with changes in myocardium and rising of
arterial pressure.
Diagnosis. History of the patients includes hereditary predilection (myoma in mother and other
reproductive organs tumors in close relatives); menstrual dysfunction, late beginning of
menarche and metabolism infringement (obesity, diabetes mellitus). Reproductive dysfunction
(infertility, pregnancy loss), induced abortions (mucous and myometrium trauma should lead to
endometrial receptor device changes),extragenital diseases, which caused endocrine and ovarian
disordes, in particular can be present in these patients.
Bimanual examination in uterine fibromyoma has characteristic signs. It includes the presence of
a large midline mobile pelvic mass with the regular contour. The mass usually has a
characteristic "hard" feel or solid quantity.
Additional methods of investigation are used for confirmation of the diagnosis.
 uterine sounding
 curettage of uterine cavity
 Hysterography
 Hysteroscopy
 Laparoscopy
Pelvic ultrasonography is the most common method to confirm the uterine myomas presence.
The ultrasonographer may suggest location, quantity, size of uterine fibroids, their sructure,
presence of destructive changes. Dynamic observation enables to supervise efficiency of the
conservative therapy, tumor growing, or, on the contrary, its reduction under the influence of
treatment.
Uterine fibroids' complications
Prolapse of submucous fibroid (cervical protruding myoma)
Submucous fibromyoma is accepted by uterus as an ectogenic body. Fibroid descent to the
inferior portion of uterus, irritating the isthmus receptors. It results in myometrial contractions,
cervical dilation and uterus pushes out fibroid into vagina. Pedunculated tumor is connected with
uterus. If pedicle is short, it can result in difficult complication — oncogenetic inversion due to
prolapse of the submucous fibroid. Speculum examination should be performed for confirmation
of this diagnosis: cervical protruding myoma is visible.
Treatment Submucous tumor can be easily removed by the incision of long pedicle by clamping
the base through the cervix. The pedicle is then ligated. Such removal of fibroid can lead to
uterine perforation when the pedicle is short and wide. These patients need hysterectomy.
Torsion of uterine fibroid
Torsion of uterine fibfoid is a very common in subserous location. Clinically it is characterized
by crarfiping pain, signs of peritoneal irritation, fever, urinary frequency and symptoms of rectal
pressure. In this situation necrosis and infection are common.
Surgical treatment Myomectomy is more commonly done when abdominal myoma location.
Myomectomy should be the operation of choice in case of single subserous pedunculated tumor
Uterine fibroid' necrosis
Necrosis of uterine fibroid results from blood supply disorder of the tumor, occuring due to rapid
growing, pregnancy, mechanical accident, and postmenopausal atrophy. It leads to tumor edema
and pseudocapsule hemorrhages
Clinically it is characterized by cramping pain which enforces during palpation. Signs of
peritoneal irritation are found. Fever and leukocytosis accompany severe degeneration.
Treatment is surgical removal.
Uterine fibroid' suppuration
Uterine fibroid's suppuration arises primarily very seldom. Sometimes it is a result of necrosis.
Submucous and interstitial uterine fibroids may be suppurated. The serious septic state demands
supracervical hysterectomy (subtotal) or total hysterectomy.
Pseudocapsule' and uterine fibroid' vessels rupture
Pseudocapsule' and uterine fibroid' vessels rupture happens very seldom. It is accompanied by
severe pain, signs of intraabdominal hemorrhage (hemorrhagic shock).
Uterine myoma and pregnancy
Pregnancy at fibromyoma of uterus comes mainly at subserous and interstitial location of uterine
fibroids. Submucous fibroids manifest with pregnancy progressing.
Diagnosis of pregnancy in such patients represents appreciable difficulties. During the
pregnancy there is a threat of its interrupting as the result of fibroid blood supply disorder (its
necrosis, pseudocapsule hemorrhage). The function of urinary bladder and rectum is broken.
Fetal position is frequently incorrect — oblique or transversal one. Breach presentation is
common if the myoma does not let the fetal head get into pelvic inlet. Preterm rupture of
amniotic fluid, primary and secondary dystocia of labor are common.
Cesarean section should be pcrfoimed if the nodes are placed behind the course of the genital
canal and block the plane of pelvic inlet. Vaginal delivery is recommended in all other cases of
labor. Postpartum hemorrhage happens in the third period of labor. Uterine fibroid should
undergo involution until their complete regress in women with high-grade lactation during the
further duration of puerperium.
TREATMENT OF UTERINE MYOMA
Treatment of fibromyoma should be operative and conservative.
Indications to operative treatment are: myomatous uterus larger than 12-week of pregnancy,
acceleretion of tumor growing, presence of such symptoms as pam, bleeding, secondary anemia;
myoma's complications; suspicion on malignant degeneration and combining with endometriosis
and endometrial hyperplasia. Operative treatment is performed in case when the patients have
contraindication to hormonal treatment. These contraindications are: thromboembolism and
thrombophlebitis, varicose phlebectasia, hypertension, operation concerning malignant tumors m
the past, no effect from hormones.
Surgical interventions are divided into radical and conservative — plastic ones.
Radical operations are in uterine removal — total hysterectomy or supracervical hysterectomy
Hysterectomy should be performed in 45-year-old women and older during tumor growing in
menopause, presence of cervical and endometrial pathological changes (dysplasia, erosion,
polyps, scars), combination of fibromyoma with precanserous lesions of uterine cervix and
uterus, endometriosis, cervical and isthmic myoma Supracervical hysterectomy is performed in
all other cases
Conservative-plastic operations are carried out for reduction or preserving of female menstrual
and reproductive functions. Their using is justified in young women for anatomo-functional
safety of uterus, fallopian tubes, ovaries and ligaments.
Conservative treatment of uterine fibromyoma has been confirmed patho-genetically and is
directed on correction of hormonal state, treatment of anemia and metabolic dysorder, inhibition
of tumor growing.
Indications. Conservative treatment is recommended at any age, lr case of myoma duration with
poor symptoms or without any symptoms, at presence of contraindications to operative
treatment.
Conservative therapy includes a diet with the usage of products, which contain A,E,K,C
vitamins, such microelements as copper, zincum, lodum, iron, antianemic therapy, vitamin
therapy, uterotomc drugs for decreasing of menstrual hemorrhage, lodium drugs should provoke
inhibition of estrogenic secretion at ovaries 0,25% solution of potassium iodide should be taken
in a dose of 15 ml once or twice per day continuously during 6-10 months. It is nessesary to
combine lodium drugs with phytotherapy — 60 ml of potato juice per day .Electrophoresis of 1-
2% solution of potassium iodide is commonly used 40-60 procedures are needed for the
treatment course.
Hormonal therapy. Gyfotocyn is given intramusculary in the dose of 1 ml during 12-15 days
since 5-7 day of menstrual cycle during 6-8 cycles. This medicine is recommended at
menorrhagia of the patient at any age.
Androgens could be applied at uterine myoma in the period of penmeno-pause Its effect can be
achieved by pituitary gland suppresion Androgens can result in reduction of uterine size,
endomenal atrophy, ovaries follicular depressing. Methylandrostendiolum is prescribed 50 mg
per day during 15 days in the follicular phase of reproductive cycle for 3 to 4 months.
Methyltestosterone is administrated in 2 pills under the tongue three times per day during 20
days with 10-day time-out for at least 3 months.
Hestagens have been used in uterine fibromyoma because of its antiestrogenic effect. First line
progestines are Progesterone in a dose of 5-10 mg intramusculary once per day for 10-12 days in
luteal phase of a reproductive cycle or 2 ml 12,5 % solution of 17- Hydroxyprogesterone
Capronate intramusculary on 12-14 day of a cycle for at least 3 months are prescribed.
Pharmacologic removal of the ovarian estrogen source can be achieved by suppresion of the
hypothalamic-pituitary ovarian axis by the use of gonadotropin-releasing hormone (GnRH)
agonists. Buzerelinum, gozerelinum and gestrmol belong to the essentially new medicines that
are a gonadotropin-releasing luteal hormone agonists. Buzerelinum in a dose of 200 mg is
administrated subcutane-ously for the first 14 days of reproductive cycle, then endonasal
prescription in the dose of 400 mkg per day for 6 months. Zoladex-Depo is applied subcutaneous
in a dose of 3,6 mg once a month for at least 6 months. This treatment is commonly used for 3 to
6 months before the planned hysterectomy, but it can also be used as a temporizing medical
therapy until the natural menopause comes. GnRH agonists can not only result in reduction of
uterine size, but also lead to a technically easier surgery with significantly diminished blood loss.
HYDATIDIFORM MOLE (Molar pregnancy)
Hydatidiform mole is one of the forms of trophoblastic disease (pathology of conceptus) which is
characterised by abnormal proliferation of syncytiotro-phoblast and replacement of normal
placental trophoblastic tissue by hydropic placental villi. Hydropic villi are up to 3 cm in
diameter and look like a mass of grape-like vesicles.
The ethiology and pathogenesis of trophoblastic disease is unknown. Molar pregnancy may be
divided into complete mole and incomplete (partial) hydatidiform mole. Complete hydatidiform
mole is identified macroscopically by edema and swelling of virtually all chorionic villi with a
lack of fetus or amniotic membranes. It is developed during the first weeks of pregnancy.
Incomplete (partial) hydatidiform mole is often associated with the identifiable fetus or with
amniotic membranes. Grossly, placenta has a mixture of normal and hydropic villi that look like
mosaic.
The diagnosis of invasive mole (also called chorioidcarcinoma detruens) rests on the
demonstration of complete hydatidiform mole. Hydropic villi invade into the myometrium on
different distances destroying muscle elements and vessels. It is similar to tumor growing.
Clinic. Hydatidiform mole is characterised by such main symptoms as:
 uterine size/dates discrepancy (uterine enlargement greater than expected for gestational dates)
 tigh-elastic uterine consistancy
 numerous painless spotting with the fragments of edematous trophoblast (absolute sign)
 other signs and symptoms, including visual disturbances, severe nausea, vomiting, marked
pregnancy-induced hypertension (preeclampsia), proteinuria
 absence of positive signs of pregnancy (fetus is not found by ultrasound and physical
examination, heart tones of the fetus are absent)
 "snowstorm" appearance of hydatidiform mole during the ultrasound examination
 great increasing of hormones in urine
 presence of large adnexal masses (theca lutein cysts) as the result of high levels of ChGT
Treatment. In most cases of molar pregnancy the definite treatment is removal of intrauterine
contents. Uterine curettage is do by dilation of the cervix followed by suction curettage (large
danger for perforation), vacuum aspiration, digital removal of mole (in the case if cervical canal
passes 1-2 fingers) with the following curettage.
With cases involving 24 weeks' gestational size, an alternative to suction evacuation is induction
of labor by prostaglandin and Oxytocin. Hysterectomy should be performed in case of excessive
bleeding. All removed tissues should undergo histologic examination.
After reception of histological research results, that confirm the diagnosis, the woman is sent to
oncologist's consultation where they will decide whether chemotherapy (Methotrexatum) is
necessary.
1. Clinic of uterus fibromyoma.
2. Diagnostics and differential diagnosis of uterus fibromyoma.
3. Indication to surgery of uterus myoma.
4. Pathogenesis of uterus myoma.
5. Classifications of uterus myoma.
6. What is a hormonal status of the patients with fibromyoma?.
17. Methods of treatment of uterus myoma.
References
412.

for practical lesson 4 course

FAMILY PLANNING
TOPIC 6. PELVIC INFLAMMATORY DISEASE.

Objectives: to learn how to diagnose and prescribe special therapy for mian women with
inflammatory diseases of the female genitals.
II. Aim:
Professional motivation: The rate of inflammatory diseases is over 60% of all gynecologic
diseases and about 30%patients of women’s hospitals have the inflammatory processes of the
genital organs. Especially the quantity of inflammatory diseases has enlarged because of an
increased sexual activity at young age, permissive sexual attitude, prostitution. Those at the
highest risk are young unmarried women with many sex partners. Primarily inflammatory
diseases affect human fertility because of infections of the female upper genital tract and their
consequences. Women with persistent viral infection are at particular risk for cervical dysplasia
and intrauterine fetal death.
A student should be Know:
Basic level:
1. Normal vaginal microflora.
2. Vaginitis (colpitis).
3. Acute endometritis.
1. Inflammatory diseases of the external female genitals
2. Classification of diseases of the external female genitals
3. Examination and urgency aid for a women with inflammatory processes
4. Bacterial vaginosis
5. Acute and chronic endometritis
6. Salpingoophoritis
7. Tuboovarian abscess
1. Collect special gynecological history, assess the results of laboratory studies (general and
biochemical analyzes of blood, urine, blood coagulation system, etc.). inflammatory diseases
of female genitals
2. Gynecological studies in inflammatory diseases of female genital mutilation
3. Taking material from the vagina, urethra and cervix.
4. Evaluate the results of bacteriological and serological study.
5. Evaluate the results of ultrasonography in inflammatory diseases of female genitals
6. Make a plan examination and treatment of inflammatory diseases of the pelvic organs
(Bartolinitis, vaginitis, salpingitis and ooforitis, Metro endometritis, pelvioperitonitis)
Key words and phrases: inflammatory diseases.

INFLAMMATORY DISEASES OF THE FEMALE GENITALS
The rate of inflammatory diseases is over 60% of all gynecologic diseases and about 30%
patients of female hospitals have the inflammatory processes of genital organs. Especially the
quantity of the inflammatory diseases has enlarged because of the increased sexual activity at the
young age, permissive sexual attitude, prostitution. Those at the highest risk are young unmarried
women with multiple sex partners. Primarily inflammatory diseases affect human fertility
because of infections of the female upper genital tract and their sequel. Women with persistent
virus infection are at particular risk for cervical dysplasia and intrauterine fetal death.
Normal flora has a significant role in defense against infection by genital pathogens. The
female genital tract, especially the vaginal secretions, contain from 108 to 109 bacteria per gram
of fluid examined. Lactobacilli produce lactic acid from glucose keeping the vagina at an acidic
pH (3,8-4,2). Glycogen is metabolized by vaginal epithelial cells to glucose, which then serves as a
substrate for Lactobacillus.
Normal vaginal microflora contains: Lactobacillus (70-90%), Staphylococcus
epidermalis (30-60%>), diphteroids (30-60%>), Hemolytic Streptococci (10-20%), nonhaemolytic
streptococci (5-30%>), Escherichia coli (20-25%), Bacte-roides (5-15%), Peptococcus (10-60%),
Peptostreptococcus (10-40%), Clostridium (5-15%).
Presence of pathogenic flora without inflammation isn't a sign of pathologic processes.
It is considered that normal vaginal flora is represented by Lactobacillus. But not only
Lactobacillus acidophilus provide the self-cleaning of the vagina. The normal vaginal ecosystem
of reproductive age women contains 7 kinds of Lactobacillus: L acidophilus (42,8%), L.
Paracasei, L. Fermentum, L. Plantarum (10-18,6%)), L.cateforme, L.corineformis, L. Brevis (2,5-
5,7%), H202 producing Lactobacillus may play an important role in acting as a natural microbicide
within the vaginal ecosystem.
Variation in vaginal colonization by Lactobacillus and other organisms could relate to
estrogen level metabolism products of vaginal microflora, vaginal pH, and the type of
Lactobacillus initially colonizing the vagina. Many endogenic and exogenic factors may change
the balance of the vaginal ecosystem. Some vaginal microorganisms may cause the inflammation
in certain conditions. Both vaginal and cervical epithelial cells have the capacity to convert
glycogen to glucose, which is further metabolized to lactic acid. Vaginal acidity depends on
adequate levels of estrogens as well as the presence of lactic acid-producing bacteria such as
Lactobacilli. Concentrations of lactobacilli are probably important determinants of vaginal pH as
well. The increased concentration of lactic acid producing bacteria in the vaginal fluid may result
in a lower pH which determines decreased susceptibility to infection. Estrogens have a direct effect
on the number of organisms and composition of the bacterial flora. The mucosal surface provides
protection from invading pathogens. Mucous may act to eliminate a variety of pathogens or
antigens. Mucous also serves for attachment of immunoglobulin A, lysozyme, lactoferrin and
other biologically active substances. Mucous in the female genital tract is under hormonal
control. Any abnormalities with low estrogen secretion and decreasing of estrogen level with age
may damage defense mechanisms of the female genital tract. Using of contraceptives, shower can
effect into vaginal ecosystem by changing vaginal pH, altering the vaginal fluid by direct dilution.
Bartholinitis
Bartholinitis is an inflammation of Bartholin's gland (large gland of vaginal vestibule). It
may be caused by Staphylococcus, E.coli and N. gonorrhea. Any type of the pathogen initiates
ductal inflammation and obstruction that can lead to Bartholin's abscess. There can be serous, serous-
purulent, or purulent inflammation.
Obstruction of the opening of the main duct into the vestibule leads to abscess formation.
Infection of Bartholin's glands can lead to secondary infections, abscess or cyst formation (fig
85). When the gland becomes full and painful, incision and drainage is appropriate. Patients with
abscess usually require abscess incision with insertion of the catheter in abscess cavity. Recurrent
infection from vaginal flora and mucous cyst formation are common sequelae of bartholinitis. If
the infection of gland is caused by N. gonorrhea specific antibacterial treatment is prescribed.
Vulvitis
Vulvitis is a vulvar inflammation. It may be primary and secondary. Primary vulvitis is
caused by local irritants (including feminine hygiene sprays, deodorants, tight-fitting synthetic
undergarments in women with obesity or diabetes mellitus. Secondary vulvitis are caused by
accompanying discharge from vagina. Reduced estrogens levels in reproductive age women, and
more frequent in girls and menopause women may lead to vulvitis.
Clinic. Erythema, edema of vulva and skin ulcers are all indices of the infection.
Patient's complains are itching or burning. Excoriation caused by the patient's scratching
of the skin of vulva are often seen in vulvar irritation.
To relieve inflammation and itching the main suspected cause must be removed. The
therapy includes local application of boric acid solution or KMn04 solution. Candidasis is
treated with Gyno-paveril 150mg in suppositories — 3 days, or Orungal lOOmg twice a day
during 6-7 days orally, and then one capsule per day every first day of menstrual cycle during
3-6 cycles. Treatment with local antibiotics and steroids is successful.
Vaginitis (colpitis)
Vaginitis (colpitis) is an inflammation of vagina. It is the most frequent cause of visits
to gynecologists. It may be caused by Staphylococcus, Streptococcus, E.coli and other.
Excessive vaginal discharge is associated with an identifiable microbiologic cause in 80%
to 90%of cases. Hormonal or chemical causes account for most of the remaining cases. Vaginitis
may be acute, subacute and chronic. There are two forms of vulvitis: purulent and granulosa-
diffusional.
The main symptom is the increased, gray-white or yellow discharge generally serous or
purulent with rancid odour. The patients complain of dysuria, vulvar itching, burning and
dyspareunia. Examination may reveal edema or erythema of vulva and vagina, petechia or
patches in the upper vagina or on the cervix. In case of chronic vaginitis all these signs are not so
expressed.The cultures from vagina, cervix,urethra, ductus of Bartholin's gland should be
microscopically examined.
Treatment of nonspecific vaginitis is comlex:
• using of antiinflammatory medicines
• treatment of neuroendocrinologic and immunodificiency conditions
• treating of male sexual partner; patients should avoid sexual contacts while therapy
Local treatment includes using of syringing with antiseptic fluid (KMn04, furacilin,
chlorhexidin) no more than 3-4 days. In case of acute or chronic vaginitis laser therapy may be
used.
Metronidazol (vaginal suppositories), chlorhinaldin, terginan, betadin, gyno-paveril may be
prescribed. For normalization of vaginal ecosystem solkotry-chovac, vagilak, Lactobacterin and
Bifidumbacterin are used.
Bacterial Vaginosis
10-25% of all gynecologic patients have this disease. Among sexually transmitted diseases,
bacterial vaginosis is diagnosed in 60-65%> of women. Bacterial vaginosis is a result of an
overgrowth of both anaerobic bacteria and the aerobic bacteria Gardnerella vaginalis. Anaerobes
and G. vaginalis are normal inhabitants of vagina, but these bacteria overgrowth dominant of the
normal Lactobacillus flora results in the appearance of a thin, fishy odor, gray vaginal discharge
that adheres to the vaginal walls.
A small amount of vaginal discharge may be normal (2ml) particularly at the midcycle.
Bacterial vaginosis causes an increased vaginal discharge (15-20ml), vulvar irritation, pruritus,
dysuria and foul odour.
The diagnosis of bacterial vaginosis is based on the presence of the following
characteristics of the discharge:
• pH is higher than 4,5
• a homogeneous thin appearance
• a fishy amine odour produced by anaerobes when 10% KOH is added
presence of clue cells (vaginal epithelial cells to which organisms are attached).
Cultures aren't helpful because anaerobes and Gardnerella vaginalis can be recovered
from normal flora of healthy women, but the concentration of both bacteria is higher in
patients with bacterial vaginosis (fig. 86). Factors that lead to overgrowth of G.vaginalis and
anaerobes have not been identified.
Treatment includes elimination of anaerobic agent of microflora, inducement of local and

general immunity and then the normal microflora should be renewed.
Oral using of metronidazol (Flagyl) 500mg twice a day for 7 days or by intravaginal
Metrogel 0,75% cream twice a day for 5 days, 2% Clindamycin cream (Cleocin) once daily
for 7 days.
For normalization of vaginal microflora the local bifidumbacterin insertion or 2-3%)
solution of Lactic acid is used. The treatment of the male parthner with Metronidazol can be
advocated only when bacterial vaginosis recurs, but effectiveness is not proven.
Endocervicitis
Endocervicitis is the inflammation of mucosa layer of the endocervix. Bacteria cause
infection of the columnar epithelium. Chlamidia trachomatis, Mycoplasma, Trichomonada
vaginalis, N. Gonorrhoeae, viruses, Candida, E.coli, Staphylococci cause endocervicitis.
Cervix is constantly exposed to trauma during childbirth, abortion.The abundant
mucus secretion of the endocervical glands both with the bacterial ascend from the vagina
creates a situation that is advantaging to infection.
The inflammatory process is chiefly confined to the endocervical glands. The squamous
epithelium of the exocervix may be involved into the process called acute exocervicitis. The
extent of endocervical involvement as compared with exocervical one appears to have some
relation to the infecting agent.
Chronic cervicitis manifestation is cervical erosion. Erosion indicates the presence
around the cervical os a zone of infected tissue that has a granular appearance. It implies the loss
of superficial layers of the stratified squamous epithelium of the cervix and overgrowth of
infected endocervical tissues.
The inflammatory process stimulates a reparative attempt in the form of an upward
growth of squamous epithelium, causing some of the ducts of the endocervical glands to be
obstructed. Retention of mucus and other fluid within these glands results in the formation of
Nabothian cycts. These cysts are endocervical glands filled with infected secretion. Their ducts
become secondarily included into the inflammation and reparative processes.
The most important in the diagnosis of chronic cervitis is the exclusion of the malignant
process. Before the begining of treatment, examination with colposcope should be carried out.
The cervicitis may appear as a reddish granulation raised above the surrounding surface, giving
the impression of being papillary.
A Papanicolaou smear should be obtained and suspicious areas should undergo biopsy.
Treatment Acute cervicitis is treated with appropriate antibiotics (it depends on bacterial
agent). Local treatment of acute phase is a real danger of dissemination of infection. Laser therapy is
used in treatment of acute and chronic cervicitis.
Electocautherization is the traditional treatment of chronic cervicitis, especially with
erosion, cervical ulcers or ectropion. Nowadays cryosurgery or laser surgery has replaced
electrocautherization.
Acute endometritis
Acute endometritis is an inflammation of endometrium (mucus layer of uterine). It may
occur in such cases as: endometritis after uterine curettage or suction and puerperal endometritis.
Endometritis is caused by bacterias, viruses, mycoplasmas. The most frequent the associations of
3-4 anaerobic bacteria and 1-2 aerobic are the main reason of endometritis.
Anaerobic bacteria compose apart of the normal cervicogenital flora. There are two known
mechanisms which cause anaerobic infection: antibiotic selection that preferentially inhibits
aerobic bacteria and tissual trauma that occurs after surgery which reduces the redox potencial.
Anaerobes produce odorous metabolic products.
Uterus has endometrium factors of local immunity. There are T-lymphocytes and other
factors of cellular imunity in endometrial stroma. Lymphocytes and :utrophiels normally appear
in the endometrium in the second half of menstrual 'cle; their presence does not necessarily
constitute endometritis. The appearing 'plasma cells represents immune response, usually to
foreign bacterial antigen. The organism should be cultured before applying of antimicrobal
therapy, s anaerobes compose a part of normal flora, deep tissual cultures not mtaminated by
surface bacteria are required. Forty eight or more hours are quired for anaerobe recovery, and
treatment usually is based on clinical signs, here are nonspecific and specific endometritis.
Specific endometritis is caused у М. Tuberculosis, N. Gonorrhea, Chlamidia trachomatis,
Actinomyces.
Fig. 87. Spreading

of inflammatory process
(scheme)
a — metroendometritis
b — parametritis
с — salpingitis
Clinic. Fever is the characteristic feature in the diagnosis of endometritis, nd it may

be accompanied by uterine tenderness. If the infection has spread to he parametrium and
adnexa, tenderness may be present there as well. Temperature :levation is probably proportionate
to the extention of the infection and when :onfmed to the decidua, the cases are mild and
there is minimal fever. Chills nay accompany fever. Women usually complain of abdominal
pain. There is enderaess on one or both sides of the abdomen and parametrial tenderness is
ilicited upon bimanual examination. The uterus is lightly enlarged.
A leukocytosis and increased erythrocyte's sedimentation rate is revealed n patient' blood
test. In some cases acute endometritis may become a chronic me;
Treatment Various choices of initial antibiotic therapy are used. Most of them are
successful. Single-agent therapy has the benefit of easy administration; Cephalosporins such as
Cefotetan and Cefoxitin are commonly used. A combination of Ampicillin and Aminoglycoside
is also popular. The combination of Clindamycin with Gentamicin or Metronidasol with Unasyn
(Ampicillin with Sulbuctam) and Gentamicin is applied. It is desirable to provide additional antibi-
otic coverage if there has been no responce within 48 to 72 hours. Intravenous antibiotic therapy
is continued until the patient is asymptomatic and afebrile period lasts for at least 24 hours.
Local uterine douching with antiseptic solution of chlorhexidin or furacilin has a good
effect. In some cases uterine curettage is performed after temperature normalization.
Chronic endometritis
Chronic endometritis is a sequale of untreated acute endometritis or nona-dequate
treatment of postabortion or purperal endometritis. The chronic endometritis sometimes is
associated with the use of intrauterine device (IUD). In some cases it may occur without acute
stage.
Clinic. The chronic endometritis results from organisms that are normally in lower
genital tract (Protei, E. Coli, Staphylococcus, Mycoplasma). Bacteria that can be recovered are
usually of low pathogenicity, but more virulent intrauterine bacteria occasionally cause the
serous purulent' discharge, abnormal uterine bleeding and moderate uterine tenderness.
Diagnosis is based on anamnesis and clinical manifestation. It could not be diagnosed unless
plasma cells are found in the endometrium. Ultrasonography can identify gas vesicules in uterine
cavity, hyperechogenic places (local fibrosis, sclerosis) in basal layer of endometrium.
Treatment. A complex treatment is used. It includes a medicines for curing of
accompaning deseases, desensibilisative medicines and additional general health measures,
vitamines.
Physiotherapy has an important role. It improves pelvic hemodynamics. Diathermy on
lower abdomen, electrophoresis with copper, zinc, ultrasound, inductothermy, laser radiation are
used. If during physiotherapy the process becomes strained antibiotic therapy is recomended.
While remission antibiotic using is not proved.
Physiotherapy promotes to activation of hormonal ovarian function. If effect is not enouph
than a hormonal therapy is used (taking into account the patient's age, term of deseases, degree
of ovarian hypofunction). Health resort treatment is effective (balneologic therapy, mudcure
resort).
Salpingoophoritis
Salpingoophoritis is the inflammation of the uterine tubes and the ovaries.
Salpingoophoritis is the most frequent among all pelvic inflammatory deseases. Most cases of
oophoritis are secondary to salpingitis. The ovaries become infected by the purulent material that
escapes from fallopian tube. If the tubal fimbriae are adherent to the ovary, the tube and ovary
together may form a large retort-shaped tubo-ovarian abscess.
Most patients with salpingoophoritis have lower abdominal, adnexal tenderness
(unilateral or bilateral) purulent cervical exudate or purulent vaginal discharge (fig. 88).
Clinic. There are four stages of salpingoophoritis. The first — salpingitis without
irritation (inflammation), of the peritoneum, the second—with signs of peritonitis, the third with
occlusion of uterine tubes and tuboovarian abscess and the fourth is the rupture of tuboovarian
abscess. During bimanual examination adnexal inflammatory mass is revealed.
The diagnosis of salpingoophoritis is based on the history, physical examination and
laboratory tests. Besides that additional ultrasonography and laparoscopy can be used.
Laparoscopy provides the most accurate way to diagnose the inflammatory process and its
stage. It should be used in cases when the diagnosis is unclear, especially in patients with severe
peritonitis, to exclude a ruptured abscess and
Fig. 88. Acute salpingoophoritis

appendicitis. Besides diagnostic laparoscopy is used to provide treatment procedures.
Ultrasound can be used to distinguish the presence of an abscess from an inflammatory
mass within the adnexal mass. It may also be helpful in defining mass in the obuse patient or if the
bimanual examination is unsatisfactory because of the excessive tenderness.
Treatment. All patients with acute salpingoophoritis should be hospitalized. Adequate
therapy of salpingitis includes the assessment of severity, antibiotic treatment, additional general
health measures.
Before the culture test performing the antibiotic therapy is provide with broad spectrum
antibiotics. The most effective is the combination of Clindamicin with Chloramphenicol,
Gentamicin andLincomicin, Doxycyclin, Clacid, Cefobid, Cyfran, Claforan, Dalacin С and
Unasyn.
When anaerobic agents are suspected metronidazol should be used, in severe cases
intravenously. After temperature normalization and cessation of peritonitis signs antibacterial
therapy is continued for 5 days. Detoxycation is indicated and is provided by using of 5% glucose
solution, polyglucin, reopolyglucin, solutions of proteins, correction of pH balance by using of 4%
solution of Sodium bicarbo-nates. Among physical methods of treatment cold on the lower part of the
abdomen is used. Appropriate antibacterial treatment is combined with laparoscopy active
drainage.
The tuboovarial abscess is drained of pus by puncture and rinsed with bacteriostatic solution
and local application of antibiotics. In subacute stage aloe, ultraviolet radiation,
authohaemotherapy is used. They prevent the chronic processes.
Chronic salpingoophoritis. In most cases chronic salpingoophoritis is the sequale of non
treated acute process. Chronic stage of the process is characterized by tubal occlusion with
periovarial adhesions, tubal dysfunction (fig. 89).
Clinic. The main complains of the patient are: mild tenderness in lower part of abdomen
that becomes severe during menstruation. Pelvic nerves have more painful sensitivity (pelvic
plexitis, ganglionevritis due to chronic inflammation). In some cases menstrual dysfunctions such
as oligomenorrhea, polymenorrhagia, algodismenorrhagia occur. Changing in uterine tubes and
hypofunction of ovaries lead to infertility or miscarriage. Secretory dysfunction like vaginal
discharge or cervical exudate may be observed as a clinical finding of colpitis or endocervitis.
Some patients complain of low libido, painful coitus, dysfunction of urinary bladder, liver
tenderness.
Menstrual dysfunction (menorrhagia or metrorrhagia) is the most frequent symptom of
chronic salpingoophoritis as a sequel of disorders of neurohomoral regulation of menstrual
function. Metrorrhagia often occurs after cessation of menstruation and then the differential
diagnosis should be made in case of ectopic pregnancy.
Fig. 89. Chronic salpingoophoritis
Diagnosis. Correct history taking (reveal of inflammation after abortion, delivery or

dilatation and curettage) makes it possible to suspect the chronic inflammatory process.
Primary chronic salpingoophoritis is found in more than 60% of cases. Some information
gives physical examination and laboratory tests. Bimanual examination gives nonspecific
information. Enlargement, consistency and degree of adnexa mobility should be examined.
Sometimes because of peritubal and periovarian adhesions the sizes and mobility of adnexa
are changed.
Additionally, ultrasound and laparoscopy, hysteroscopy should be held. Tomography
or endoscopy may be used. Laparoscopy is the most informative diagnostic method to
differentiate salpingoophoritis, external endometriosis, uterine myoma with inflammatory
changes, cysts. Disorders of adjacent organs (bladder, intestine) while serous inflammation is
present without structural changes. But women with disorders of urinary tract, gastro-
intestinal tract must be additionally examined (urography, irrigoscopy).
Treatment of chronic salpingoophoritis is provided with minding of pathogenesis and
clinic. Antibiotics are indicated in acute period, when there are signs of inflammation.
Nonsteroidal antiinflammatory drugs (Voltaren, Butadion) are prescribed. To stimulate
immune system immunomodulators are used: (Decaris, T-activin). FIBS, aloe, autohaemotherapy
are also used. Analgesia both by medicines and by reflextherapy is of great importance.
Physiotherapy is conducted in hospital while in case of acute process and remission it can be
used in ambulatory conditions. Ultrasound has analgetic and fibrinolityc influence and is
prescribed in sinusoid and modulate of high frequency. Laserotherapy is also used. To escape chronic
salpingoophoritis the acute salpingoophoritis must be treated in proper way and the quantity of
abortion should be reduced.
Parametritis
Parametritis is an inflammation of parametrium. Inflammation of the whole pelvic cellular
is called pelviocellullitis. According to international statistics these diseases are classified as acute
parametritis or pelvic phlegmona.
Infection agents may be staphyloccocus, streptoccocus, E.coli, etc. It can be caused by
one microbic agent or microbe association. It occurs after pathologic delivery, abortion, operation
on genitals. The main way of infection spreading is lymphogenic. Morphologically parametritis is
characterized by all signs of inflammation: dilation of blood and lymphatic vessels, peripheral
edema, exudation. There are 3 stages in course of parametritis (infiltration, exudation, firming).
Exudation may be serous, and very rarely it is purulent. Sometimes it undergo resorbtion and
dissolves, sometimes a fibrose connective tissue grows and leads to uterine dislocation to the side
of previous inflammatory process.
Clinic. Moderate tenderness in lower parts of abdomen, in back, high body temperature
(38-39°C), tachicardia are found. Signs of peritoneal irritation and diminished or absent bowel
sounds, especially associated with ileus, indicate more serious infection, including the possibility
of abscess formation. Fever is a characteristic feature in the diagnosis of metritis and it is
accompanied by uterine tenderness. Bimanually before or behind on left or right side of the uterus
infiltration may be palpated. It is firm and immovable. Infiltration is classified into anterior,
posterior and lateral.
Treatment begins from using antibiotic of broad coverage against a variety of common
microorganisms and is usually prescribed without cultures.
Various choices of initial antibiotic therapy are used. Most of them are successful.
Cephalosporins such as Cefotetan and Cefoxitin are commonly used. A combination of
Ampicillin and Aminoglucoside and also the combination of Clindamycin with Gentamicin are
used.
A bottle with ice on the lower part of abdomen is used in case of infiltrative stage of
disease. Bio stimulators should be prescribed. Management of a persistent pelvic abscess includes
drainage by colpotomy, or laparotomy. Intraabdominal rupture of pelvic abscess is a surgical
emergency. Sepsis may occur in association with pelvic infection, with or without frank abscess
formation. Phisiotheraputic precedures are used for rehabilitation.
Tuboovarian abscess
Tuboovarian abscess (TOA) may occur as a complication of salpingoopho-ritis. It
begins from acute purulent salpingitis when all layers of uterine tubes are involved into the
process. The tubes characteristically become swollen and redde is the muscularis and serosa are
inflamed. If exudate drips from the fimbriated mds of the tubes a pelvic peritonitis is produced
then it can give rise to peritoneal idhesions. The swollen and congested fimbriaes may adhere
to one another and produce tubal occlusion. The fimbriae may occlude tubes producing
permanent ubal infertility. The swollen and congested fimbriae may adhere to ovary, trapping he
exudate in the tube and giving rise to pyosalpinx or if the ovary becomes nfected, a
tuboovarian abscess (fig. 90). The mucosal folds may adhere to one mother forming gland-
like spaces that are filled with exudate. If the infection subsides after agglutination of the
fimbria and closure of the peripheral end of he tube, secretion accumulates and distends the
tube, forming pyosalpinx. Each •ecidive of chronic salpingoophoritis has more clinical
manifestation and is treated vith difficulty. TOA is associated with IUD, microbe association,
chronic salpingoophoritis.
Intoxication in case of TOA leads to liver disorders. Decreasing of albumin-globulin
index is observed while the level of general proteins is normal for a ong time. The degree of
these disorders depends on the time of duration of the process.
Clinic. Clinic of TOA depends on the volume of purulent damage of adnexa, duration of the
process, disorders of adjacent organs. There are some syndromes vhich are divided into local
syndrome (pain, purulent discharge, peritoneal symptoms and palpation of tuboovarian mass).
uterine body
tuboovarian abscesses
Fig. 90. Bilateral purulent tuboovarian cyst (TOA)

Inflammatory-intoxicative syndrome includes fever, tachycardia, nausea, vomiting.
Luecocytosis, decreasing of albumin-globulin index, C-reactive protein are observed in blood.
Immune syndrome (decreasing of lymphocytes and mono-cytis in blood) is found.
Syndrome of adjacent organs disorders (dysuria, urinary frequency, menstrual disorders) is
also possible.
Severe lower abdominal pain occurs, pelvic peritonitis may be present. Pain can irradiate to
back, pelvic bottom, in the chest. In such cases the examinations should be performed to exclude
pneumonia, pancreatitis, cholecystitis. Musclar defance which prevents abdominal palpation in
the lower quadrants, adnexa are tender to various degrees and cervix movement may cause pain in
case of bimanual examination. The adnexa often are either adherent to the posterior aspect of the
uterine or prolapsed in cul-de-sac, which may pull the uterine into a retroverted position. TOA is
characterized by pain and tenderness, fever or chills, temperature rises up 39°C, blood pressure
decreases. Abdomen takes part in breathing, and it is painful in lower parts. In blood analysis
elevated white blood count (9-10x107 1) erythrocytes' sedimentation rate more than 30mm/hour,
positive C-reactive protein, decreasing of albumin-globulin index till 0,8 are observed.
Sometimes there can be urinary syndrome with proteinuria, leucocyturia. There may be
disorders of filtrative kidney' function, even unuria. Changing of albumin-globulin index and
hypofybrinogenemia characterizes the liver dysfunction.
Diagnosis is based on clinic, bimanual examination, laboratory analyses and additional
methods of investigation (ultrasound, laparoscopy).
Treatment Tuboovarian abscess is treated by antibiotics, desensibilisative and
nonsteroidal antiinflammatory medicines, detoxication and immunostim-mulation. Best of all
one should combine taking of penicillin with tetracyclins. When anaerobic infection is suspected
metronidazole is used. Daily punctions of tuboovarian abscesses are indicated to remove
purulent containts.
Indications to surgical removal of tuboovarian abscess are:
• abscence of efficiency of complex treatment with usage of punctions during 2-3 days
• suspicion on tuboovarian abscess perforation; volume of surgical intervention depends on
process' spreading, woman's age and extragenital pathology
Peritonitis
Pelvioperitonitis is an inflammation of pelvic peritoneum.The polymicrobial infection
such as Escherichia coli and other aerobic, enteric, gramnegative rods, group of p-hemolytic
staphylococci, anaerobic, streptococci, Bacteroides species, aphylococci, mycoplasms cause
the process. Pelvioperitonitis occurs secon-ary. Primary process is in uterine tubes, ovaries,
uterus and parametrium. In lost cases purulent damage of uterine adnexa lasts with
pelvioperitonitis. lfection can be spread by limphogenic or blood vessels, and from uterine
tubes l case of salpingitis, especially gonococcial infection.
Clinic characterizes the acute inflammation. High temperature, severe lower bdominal
pain, fever or chills, tachycardia are common. There can be nausea nd sometimes vomiting.
Muscular defence and rebound tenderness are the ymptoms of peritoneal irritation. Anterior
abdomen wall takes part in breathing ct.Tender adnexa are present at bimanual examination.
Cervical motion causes ain. Posterior fornix is painfull.
Laboratory tests reveal increasing of white blood cell count and erythrocyte
edimentation rate. C-reactive protein levels may appear. Generall blood test hould be done 4-
5 times per day to diagnose transformation of pelvioperitonitis о peritonitis.
Treatment All the patients should be hospitalized. Ideally, the antibiotic hould be
selected according to the organism present in the fallopian tube or items, but in most cases
empiric therapy must be used. Treatment includes intravenous doxycycline and either cefoxitin
or cefotetan or intravenous clindamycin ind gentamicin for at least 4 days followed by oral
clindamicin or tetracyclin for [0-14 days. Hospitalized patients who have peritonitis but do
not have adnexal ibscess usually respond rapidly to the regimens. In the presence of an
adnexal ibscess, even if the systemic manifestations are mild, antibiotics which eliminate
3.fragilis should be selected because most pelvic abscesses contain this organism. Clindamycin,
Metronidazol, Cefoxitin, or Impinem should be used to treat pelvic ibscess. If there is an
intrauterine device it should be removed as soon as therapy s started. Surgery is indicated in
the case of ruptured pyosalpinx or ovarian ibscess. Colpotomy drainage usually is preferable
when unruptured midline cul-de-sac abscess is present. Laparotomy is required for such
problems as unresolved abscess or adnexal mass that does not subside, surgery should be
limited to the most conservative procedures that will be effective. Unilateral abscess respond
to unilateral salpingoophorectomy.
Septic shock
Septic shock is associated with infection caused gram-negative aerobic coliform
organisms those are producing endotoxins. In gynecological practice it may occur in case of septic
abortion, localized or spreading peritonitis, thrombophlebitis. Septic shock is a special organism
reaction that is expressed in development of severe systemic disorders. It may be caused by using of
broad spectrum antibiotic in high doses, that results in releasing of great amount of endotoxin.
Endotoxin, a complex cell wall-associated lipopolysaccharide, is released into the circulation
at the time of bacterial death, resulting in multiple hemodynamic effects. The subsequent activation
of lymphocytic T-cells and mass cells results in histamine and kinin activation as well as the
activation of kallikrenin and decrease in kallikreinogen and kallikrein inhibitor. These changes
result in the release of bradykinin, a potent arterial dilator. Early septic shock is a classic example
of distributive shock, related to a systemic maldistribution of relatively normal or even increased
cardiac output. Clinical findings include hypotension, fever and chills. Initial hemodynamic findings
include decreased systemic vascular resistance and high normal or elevated cardiac output. The
continued maldistribution of cardiac output leads to local tissue hypoxia and to the development of
lactic acidosis and organ dysfunction. This decrease in systemic vascular resistance is caused by the
release of vasoactive substances, as well as by vascular endothelial cell injury, which promotes
capillary plugging secondary to complement induced leukocyte aggregation. These factors lead to
increased arteriovenous shunting.
If the process continues a second hemodynamic phase of septic shock is developed. The
primary importance in this late phase is the development and progression of myocardial
dysfunction leading to ventricular failure. Studies assessing stroke work index and ventricular
ejection fraction have demonstrated depressed intrinsic ventricular function even in the early
stage of septic shock. Pulmonary hypertension, another important hemodynamic alteration is
often associated with septic shock, may have additional profound hemodynamic consequences.
As the sequalae of renal kidneys filtration disorders — the shock kidney is formed and acute
renal insufficiency is developed. Signs of liver disorders are hyperbilirubinemia, lipid
metabolism abnormalities.
Patients who recover from the initial hemodynamic instability of septic shock may suffer
prolonged morbidity secondary to endotoxin-mediated pulmonary capillary injury and
noncardiogenic pulmonary edema. Such lung failure is a major cause of death in patients whose
hypotension was prolonged and may experience acute tubular necrosis. Endotoxin mediated
endothelial cell injury and associated thromboplastine-like activity as well as prolonged shock
from any other cause may also lead to activation of the coagulation cascade and a clinical
picture of disseminated intravascular clotting syndrome (DIC).
Clinic and diagnosis. The clinical manifestation develops just after surgical operation on
infected organs. The body temperature rises till 39-40°C and is high during 1-3 days. Then the
temperature decreases, chills is a characteristic feature of the septic shock.
Among clinical findings there are hypotension without bleeding or nonade-quete to it,
tachycardia, 120-140 per minute. Decreasing of blood circulative volume leads to rising of
shock index till 1,5 (normally 0,5). Skin is pale and wet because of perspiration, later
akrocyanosis can appear. Breath disorders, like tachypnoe till 30-60 per minute, is the sign of
shock lungs. Skin may be colored in yellow, there may be blood vomiting.
The most dangerous complication of septic shock is kidney insufficiency. Clinical
manifestation at the beginning is oligouria — less than 30 ml per hour. Later anuria is
developed. All these changes in organism appear in very short time in 6-8 or sometimes 10-
12 hours.
Diagnosis is based on the following signs:
• septic organ
• low blood pressure, nonadequate to blood loss
• nervoues system disorders
• pain of different parts of body
• decreasing of diuresis
• rash on the skin
The blood temperature should be taken every 3 hours, blood pressure is measured
every 30 minutes, urine quantity must be measured. Bacterial culture from infected organ,
blood analysis, coagulogram and biochemical tests are performed.
Treatment of septic shock. The treatment of septic shock involves optimising preload relative
intravascular volume with crystalloid infusion as well as treating of the underlying infection.
Although some authorities advocate the use of colloid solutions for volume replacement, there is
noconvincing evidence that using of such solutions decreases the incidence of pulmonary edema
or adult respiratory distress syndrome. In most cases the infection is polymicrobial and broad
spectrum coverage for gram-negative and gram-positive aerobic and anaerobic organisms is most
appropriate. If an abscess is involved, promt surgical drainage after initial resuscitation is
mandatory. Patients in septic shock should be treated with dopamine hydrochloride. This agent in
doses of less than 5mg/kg/minute improves renal blood flow by means of dopaminergic
mesenteric vasodilatation; in doses of 5 to 30 mg/kg/minute, a positive inotropic effect is also
seen. The hemodynamic manipulation of patients whose hypotension fails to respond rapidly to
volume infusion may be assisted by pulmonary artery catheterization, allowing the clinician to
achieve optimal preload before the institution of inotropic or vasoconstrictive therapy. High-dose
corticosteroids are advocated (60-120 mg of prednizolone or 8-16 mg of dexamethazone). To
renew Ph balance lactosol or bicarbonate natrii are indicated.
SPECIFIC INFLAMMATORY DISEASES
(Sexually transmitted diseases)
To specific inflammatory diseases of the female reproductive organs belong tuberculosis
and sexually transmitted diseases. According to the WHO's classification, there are 21 such
diseases. Their frequency has been risen for the last years.
SEXUALLY TRANSMITTED DISEASES
(the WHO's classification)
Classic venereal diseases
Nosology Microorganism
1. Syphilis Treponema pallidum
2. Gonorrhea Neisseria gonorrhoeae
3. Chancroid Hemophilus ducrei
4. Lymphogranuloma venereum Chlamydia trachomatis
5. Donovanosis, or granuloma Callimmantobacteriumgranul
inguinale omatis
3,4,5 are mostly in tropic countries
Other sexually transmitted infections
Nosology Microorganism
A — that affect mostly genital tract
1. Syphilis Treponema pallidum
1. Urogenital chlamydiasis Chlamydia trachomatis
2. Urogenital trichomoniasis Trichomonas vaginalis
3. Urogenital mycoplasmosis Mykoplasma hominis
4. Candidosis vulvovaginitis Candida albicans
5. Genital herpes Herpes simplex virus
6. Genital warts Papillomavirus hominis
7. Molluscum contagiosum Molluscoviras hominis
8. Bacterial vaginosis Gardnerella vaginalis та mini
9. Urogenital shigellosis of збудники
Shigella species
10. Pediculosis pubis
homosexualists Phthyrus pubis
11. Scabies Sarcoptes scabiei
В — With mostly affection of other organs
1. Infection, caused by HIV Human immunodeficiency
2. Hepatitis В virus Hepatitis В virus
3. Cytomegalovirus infection Cytomegalovirus hominis
4. Amebiasis Entamoeba hystolytica
5. Lambliosis Giardia lamblia
Gonorrhea
Gonorrhea is a contagious disease caused by Neisseria gonorrhoeae. Among the
specific inflammatory diseases of the female genital tract gonorrhea takes the second place
and is in 5-25% of cases of all STDs.
Etiology and pathogenesis. Gonorrhea is caused by Neisseria gonorrhea (fig. 92).
The causative agent was found in 1879 by A. Neisser. Gram-negative N. gonorrhea is not
stable in the outer surrounding and dies quickly at the influence of antiseptic solutions, boiling,
drying, but it is rather stabile in human organism. In uncomfortable conditions they transform
into L-forms, which can transform into the usual form in the favourable conditions. In case of
chronic gonorrhea, N. gonorrhoeae are situated mostly in leukocytes and out of the cells, in
case of the acutening of the process they are found in the leukocytes.
Fig. 92. An agent of gonorrhea —
gonococus
N. gonorrhea affects mostly those parts of urogenital tract, that are covered with cylindric
epithelium: mucosa of urethra, cervical canal, Bartholin's glands ducts, mucosa of uterine cavity,
uterine tubes, ovarian epithelium, peritoneum. During the pregnancy, childhood and menopausal
period there can be gonorrheal vaginitis.
The source of infection is a person with gonorrhea.
Ways of infecting:
• the disease is sexually transmitted
• homosexual contacts, orogenital contacts
• very rarely through sponges, towels, underwear
• during labour from mother (infected eyes, vagina in girls)
Incubational period lasts for 3-7 days, sometimes for 2-3 weeks.
According to the stage of spreading the process the gonorrhea of lowei part of genital
organs (gonorrheal urethritis, endocervicitis, Bartholinitis, vulvovaginitis) and gonorrhea of upper
parts — gonorrhea ascendens (endometritis, salpingitis, pelvioperitonitis) is classified.
According to duration there are such forms of gonorrhea:
• fresh gonorrheal infection with acute, subacute, torpid passing, which lasts less than two
months
• chronic gonorrheal infection, lasting more than two months
• latent gonorrheal infection
In women the clinic of gonorrhea depends on the localization of the process, virulency of
causative agent, age of woman, organism's reactivity, stage of the disease (chronic, acute).
Fresh gonorrhea in acute forms has expressed clinical manifestations. Subacute form is
characterized by subfebrile condition, sometimes by expressed clinical symptoms, which
appeared two weeks before. Torpid gonorrhea in acute form has mild clinical manifestations or is
asymptomatic, but N. gonorrhoeae are found in the patient. Latent form is diagnosed when there
is no bacteriologic and bacterioscopic confirment, no symptoms, but person is a source of
infection. Chronic gonorrhea lasts for more than 2 months, or without establishing of the
beginning.
Gonococcal urethritis. Clinical manifestation appears within 3-5 days after infection and is
characterized by dysuria. Variable degrees of edema and erythema of the urethral meatus, purulent
or mucopurulent discharge are present.
Gonococcal Bartholinitis. It may occur when N. gonorrhea with vaginal discharge
infects the Bartholin's gland. It is manifested by edema, erythema around the duct's os. When
the occlusion occurs, pseudoabscess or Bartholin's abscess which are accompanied by purulent
process symptoms can develop.
Gonococcal endocervicitis. Inflammatory process develops in mucosal layer of the cervical
canal. Examination reveals edema and erythema of vagina and part of the cervix. There is a red
crown around the cervical os and a mucopurulent cervical discharge.
Gonococcal proctitis occurs very rarely. Rectum is involved into the process in the result of
contamination with the infected genital discharge. Clinic includes tenesmus and rectal pain.
Gonococcal endometritis is the first stage of the ascendant gonorrhea with infection of
basal and functional layer of endometrium. It is manifested by lower abdominal pain, high body
temperature, sometimes nausea, vomiting. Pain often has spasmatic character. Discharge is
sanguine-purulent or mucopurulent. Uterus is painful at palpation. Chronic endometritis is
characterized by menstrual disorders.
Gonococcal salpingitis is the infection of the fallopian tubes, mostly bilateral. In acute
stage the pain in lower part of abdomen is common. It becomes stronger, motion, nausea,
vomiting. Menstrual disorders can occur.
Smears must be taken on the 2-4th day of the menstrual cycle and after provocation in
24, 48, 72 hours, that allows to reveal N. gonorrhea.
Treatment is provided in special clinic. Sometimes the patient is treated by the
venerologist in ambulatory.
To reveal another sexually transmitted diseases clinical and laboratory examination must
be performed. While prescribing medicines the clinical form, complications and severity of the
process should be taken into consideration.
The main medicines in gonorrhea treatment are antibiotics. Gonococcal infection very often
is accompanied with trichomoniasis, chlamidiasis, candidiasis, mycoplasmosis.
Antibiotics that have influence on the following agents such as: Ciprofloxacin,
Doxycyclin, Trobicyn, Sumamed, Cephtriaxon, Afloxacin in combination with Metronidazol,
Tiberal, Naxogyn should be prescribed. The dose of antibiotics is taken according to the methodical
instructions of the Ukraine МНР and annotation of medicines.
Gonovaccine is used after ineffective antibiotic treatment and relapse in the latent fresh
torpid and chronic form of the disease (200-300 mln. of microbe bodies, in 2-3 days
intramuscularly). During pregnancy immunotherapy and antibiotics with negative influence on a
fetus are not used.
For toilet of external genital organs 0,002% solution of Chlorhexidine, Re-cutan, Baliz-2
are prescribed. Local treatment of chronic gonorrhea is conducted after disappearing of the signs
of acute inflammation. In chronic and subacute stages physiotherapeutic methods are used: laser
radiation, paraffinotherapy, mud-cure, diathermy, inductothermy, U.H.F-therapy.
The control of the results of treatment: disappearing of subjective signs and microbe
agents in all the infected organs and discharge. On the 7-10th day after medical therapy the
bacterioscopic and bacteriologic methods are used to confirm the results of treatment. If there is
no N. gonorrhea in the material, then the combined provocation is conducted: injection of
Gonovaccine (500 mln. of microbe bodies), instillation of 1% Lugol's solution in urethra, 0,5%
solution of Argentum Nitrate into cervical canal. Discharge from this organ should be examined
during 3 days. Smears are taken during menstruation and then after provocation in 24, 48, 72
hours. Such examinations are provided during 2-3 menstrual cycles. Women which have
contacts or work with children are not allowed to work.
Prophylaxis. Using of condom is the most effective prevention method. If the sexual
intercourse has happened without it, then the external genital organs should be washed with water
and soap, and after urination syringing with 0,05% Chlorhexidin solution should be performed.
Urogenital trichomoniasis
Urogenital trichomoniasis is caused by Trichomonas vaginalis and is a result f their
invasion into the lower part of genital tract and urethra.
Ethiology. Trichomonas vaginalis is a flagellate protozoan (fig. 93, 94) and t is transmitted
by sexual intercourse. It is not stable in outer environment, dies n few seconds under the influence
of antiseptic solutions, in water it dies during 5-45 minutes, and also when they wash hands with
soap, it is sensitive to drying, n human organism Trichomonas vaginalis can exist in 3 forms:
common one pear-shape form), amebiform with the expressed phagocytosis action (it can
ihagocytise mycoplasmas, N. gonorrhea and other bacteria that caused the recur-ence of
mycoplasmas or gonorrhea. This is the most spread disease among all he sexually transmitted
ones. Its frequency rate reaches 50-70% of sexually ictive women. According to the WHO
statistics, 10% of world population suffer rom trichomoniasis. Non-sexual transmission is very
seldom: when they use ;ponges, underwear, towels.
Incubation period lasts for 5-15 days, the main places of trichomonas >arasitizing are
mucose membranes of vagina, cervical canal, uterus cavity, uterine ubes, Bartholin gland's duct,
urethra, urinary bladder.
Inflammatory process develops in the infected mucous membrane: edema, lyperemia,
exudation, desquamation affects epithelial cells.
Clinical manifestations. Vaginitis, urethritis, endocervicitis, proctitis are he most
common manifestations, ascendant infection meets rarely.
Fig. 93. An agent of trichomoniasis — vaginal trichomonas

bodies. Practically they don't cause the infection. Microscopy allows to identify both
kinds of bodies. Chlamidia has a complicated antigenic structure. It is very sensitive to
disinfectant substances. At 35-37°C during 24-26 hours outcellular Chlamidia become
nonvirulent, at temperature 95-1000C they die during 5-10 minutes. In cotton material they can
survive up to 2 days at temperature 19-20°C.
The source of infection is the ill person.
Ways of transmission:
• sexual
• intrapartum (passing through the infected birth canal)
• nonsexual way (polluted hands, instruments, underwear, toilet, etc.)
Besides infection of urogenital organs, Chlamidia trachomatis can cause pharyngitis,
conjunctivitis, perihepatitis, otitis, pneumonia, other diseases (Rei-ter's syndrome).
Clinical manifestations. Incubational period lasts from 5 to 30 days. The main primary
form of chlamidial infection is endocervicitis with mild symptoms or without any. In acute stage
purulent or mucopurulent discharge from the cervix, edema and erythema of the vaginal part of the
cervix are observed. In chronic stage there is the mucopurulent discharge and pseudoerosion of
the cervix.
Chlamidial urethritis can be asymptomatic or it manifests itself by dysuria. There are no
specific symptoms for clinical diagnostics of chlamidiasis.
Salpingitis, caused by Chlamidia trachomatis, is characterized by the same symptoms
like the process caused by other bacteria.
The sequale of chlamidial salpingitis is infertility.
Diagnosis is based on the history (both partners are ill, there is the infertility). Residual
diagnosis is established after revealing chlamidias in the scrap from the cervix and vagina. The
most exact are immuno-enzyme and immuno-fluorescent methods.
Treatment. It is necessary to cure the woman and her sexual partner. The woman should
avoid sexual intercourses, alcohol, psychical and physical overload.
Medicines from the tetracyclin group are prescribed (Doxycyclin, Rondo-micyn,
Morphocyclin), Sumamed, Tarivid, Macrolids (Clacid, Erythromycin).
To prevent candidosis Diflucanum in dose 150 mg is used, Nistatin or Levorin (2.000.000 IU
per day during treatment) are prescribed. Fromilid (Clarythro-mycin), an acid-resistant antibiotic
from macrolid group is recommended. An important property of this drug is its possibility to cell
penetration, that's why Fromilid is 8 times more active, than Erythromycin. It doesn't suppress
immune system, activates phagocyto-macrophagal system and some enzymes, that take part in
destroying of pathogenic bacterias. The dose of fromilid is 500 mg twice a day during 7-14 days
in case of fresh incomplicated chlamidiosis. In chronic forms the treatment course must be
elongated till 3-4 weeks.
At urogenital chlamidial infection medicines from ftorchinolon group, Ciprofloxacin
(Ciprinol) are used. Ciprinol is prescribed in the dose of 0,5g orally or 0,2g intravenously each 12
hours during 10-14 days. During treatment the ultraviolet irradiation including sun radiation are
contraindicated.
Treatment of chlamidiasis demands from the doctor and patient accurate fulfilling of all
the indications (dose and duration of the therapy), especially at chronic, long-lasting forms of
disease. At the same time accompanying urogenital diseases should be treated. To reduce side
effects of antibiotics hepatoprotectors, antioxydants, polivitamins are used.
Urogenital mycoplasmosis
Ethiology. Microbal agents are Mycoplasma hominis, Mycoplasma genita-loum,
Ureaplasma urealiticum.
In the etiology of the inflammatory diseases of female genital organs the associaton of
mycoplasmosis with trichomoniasis, N. gonorrhea, Chlamidia trachomatis, anaerobes is of great
importance.
Mycoplasmas are transmitted sexually and they are highly spread among the population.
Clinic. Mycoplasmas infection can occur in acute and chronic form, and has no
symptoms, which are specific for this agent. It is often found in healthy women. Mycoplasmosis
is characterized by torpid course, sometimes the latent forms of the reproductive system
inflammation are observed. The agents may be activated under the influence of menstruation, oral
contraceptives, pregnancy, delivery. Ureaplasma is identified in the patients with vaginitis,
cervicitis, urethritis, in association with other bacteria the symptoms are typically and described in
the part "Nonspecific inflammatory diseases of the female genital organs".
Diagnosis. To reveal ureaplasmas the bacteriological method is used. Material is taken
from the purulent discharge of Bartholin's glands, from uterine tubes at salpingitis, tuboovatian
tumors at pelvic inflammatory disease. Test on the urease is done (colour index). It is based on
the property of ureaplasms to product urease, that changes the pH and the colour of indicator.
Serological diagnosis is also used. Immunogram in diagnosis of mycoplasmosis and other infection
(Chlamidia, gonorrhea, trochomoniases, herpes simplex virus) is indicated.
Treatment. Using of antimicrobal medicines from macrolid group (Erythromycin,
Sumamed, Roxitromycin), Tetracyclin group (Tetracyclin, Doxycyclin), Fluorochinolones
(Ciprofloxacin) is etiotropic treatment. They are prescribed for not less than 10-14 days with the
following laboratory control. Another course of treatment is immunity stimulation
(Immunoglobulin, Levamizol, T-activin, Ginseng Tincture).
Prophylaxis. Examination of the risk group (prostitutes, women with infertility,
inflammatory processes of genital organs), and keeping to the same measures for preventing sexually
transmitted diseases are used.
Candidiasis vulvovaginitis (Monilia vaginitis)

Candidiasis is a polyorganic disease, caused by yeast fungi (Candida albicans, C. glabrata,
С tropicalis) (fig. 95). It can be transmitted sexually. The most frequent localization is in vagina,
vulva, but there can be candidiasis endocervi-citis, endometritis, salpingitis.
Predisposing factors:
• endogenous long lasting diseases, such as diabetes mellitus, avitaminosis
• exogenous factors, that predispose fungal colonization and decrease the general
reactivity of the organism (long treatment with antibiotics) and local immunity in vaginal mucosa
high virulency of Candidas.
Fig. 95. An agent of candidiasis — Candida albicans

There are such kinds ofcandididas vulvovaginitis:
• primary
• antibiotics-induced (as a result of antibiotic treatment)
• as a sequale of changes in different systems of the organism (diabetes, pregnancy, using
of estrogens)
On the suppressed immunity of the organism fungi, that were previously saprophites,
become pathogenic. They adher to vaginal epithelial cells, causing superficial inflammation
and desquamation of vaginal cells. Genital candidiasis mostly doesn't cause a deep damage of
mucosa and spreading of the process, but if the agent has high virulence, it can penetrate into
intra- and subepithelium parts. In some cases there can be dissemination of candidiasis.
Clinical manifestations: Candidiasis vulvovaginitis is characterized by vulvar
itching, pruritus, cottage-cheese-like discharge.
Examination reveals edema and erythema of genital mucos with whitish adherent
discharge, that include pseudomicelium of fungi, exfoliated epithelial cells and leukocytes.
Diagnosis. Diagnosis is based on the clinical manifestations, vaginal examination,
colposcopy, bacterioscopic and bacteriological methods.
Treatment. Acute form is treated by Orungal 200 mg twice a day during 3 days; at
chronic form they use 100 mg twice a day during 6-7 days, then during 3-6 menstrual cycles 1
capsule on the first day of menstrual cycle is taken. High effectiveness is observed while using
Diflucan in dose 150 mg per 1 reception, and Gyno-pevaril — one suppository (150 mg)
during 3 days. In case of relapse one suppository (50 mg) twice a day for 7 days and
application of Gyno-pevaril creme on glans penis during 10 days is recommended. The next
step of treatment is normalization of vaginal ecosystem.
Prophylaxis: rational antibiotic treatment with keeping to optional doses and duration
of the therapy course, in-time using of antimycotic medicines with the preventive aim.
Avoiding of premarriage and extramarital relationships, condom using for preventing fungal
colonization of the female genital tract.
Syphilis
Syphilis is an infective disease, that is transmitted sexually.
Etiology. The pathogene is Treponema pallidum. In microscopic examination it has spiral
shape and is movable. Optional temperature for reproduction of Treponema is 37°C. It is very
sensitive to different external conditions. It dies during boiling, drying, under the influence of
different chemical agents and 90% ethanol. While working with the infected persons hands are
cleaned with ethanol. It prevents from infection at contact with syphilitic rash having Treponema
pallidum on its surface. At 40°C (temperature for keeping blood for transfusion in refrigerator)
Treponema pallidum dies in 24 hours.
The source of infection is the infected person.
Ways of transmission:
• sexual perversion (oro-genital, homosexual contacts)
• transplacental — congenital syphilis, when a child is infected by transplacental
transmission
• professional — while examining the ill person with wet surfaced rash
• transfusion (very rarely) — as a sequale of blood transfusion from the ill person
Clinical manifestations. 3-4 weeks pass from the moment of agent penetration into
organism and till the first manifestations of the disease. This is the so-caled incubational period.
The microbe is already in human organism, but there are no complications and signs of the
disease.
After finishing of incubational period the first signs appear only in the area of agent
inoculation. This is the so-called primary lesion (ulcerated shancre) (fig. 96). It appears as a
painless indurated papula on skin or mucos with erosion or necrosis of the surface. Is a hard-
based, well-
Fig. 96. Ulcerated shancre of labia major
circumscribed lesion. There is no inflammation around it and it has smooth surface with
serous discharge. Its
size is from several mm to few cm, and it can be coated with whitish discharge like old
fat. On mucos of genital organs or anus it is like fissure. Sometimes shancre can gangrenize.
Indurative edema belongs to the atypical forms of shancres. Labia major enlarges in size, they
are firm and painless. Chancre on pubis, thighs and cervix can occur rarely.
If the shancre is situated on the genital organs, then after nearly 7 days the inguinal
lymphatic nodes enlarge on one side (scleradenitis, bubo), rarely on both sides. They are
firm, movable, painless. They are not connected with skin and have no suppuration. This is
the primary syphilis, that lasts for 6-8 weeks from the appearing of the shancre (the first 3-4
weeks is primary seronegative period, when Wassermann reaction is negative, and next 3-4
weeks, when Wassermann test is positive). Diagnosis in this period is based on the history
taking (sexual contact, incubation period, examination of sexual partner, revealing of Treponema
pallidum on shancre surface, positive serological reactions (Wasser-mann's,
immunofluorescence).
Without identification of the agent or positive serological reactions diagnosis of syphilis
is not proved.
After 6-8 weeks of shancre development, the body temperature may rise, there is the
night headache, bone pain can appear. This is the so-called/?ro<iroma/ period. During this time
the agents are reproducted intensively, they appear in blood (treponems sepsis) and there is
disseminated rash on skin and mucosal layer. There appear the signs of secondary syphilis.
Firstly roseolas (little red macula 0,5-1 cm in size) appear on body skin. They disappear for a
while after the finger pressure, don't protuberate over the skin level. After some period
papulas, very rarely pustulas or hair shedding appear. In this time on skin and mucos of the
female genitals papula (erosion nodes) can appear. They are firm, without inflammation, up to
1 cm in diameter, with moist surface, rich in microbal agents (Treponema pallidum), that make
them very infectious. There are no subjective feelings. As a result of irritation these nodes
enlarge, indurate and transform into the so-called condyloma lata, 0,5-1 cm and more in
diameter, indurated, prominating above skin level, without signs of acute inflammation,
painless, with smooth or tuberous, sometimes with moist surface.
There are plenty of agents on the surface of condyloma lata and they are very
contagious. They should differ it from viral pointed condylomas (soft, on the pedicle, with
lobular, like cauli-flower structure).
Diagnosis is confirmed by presenting erosional papulas and condyloma lata, positive
serological reactions (Wassermann's reaction, reaction of immobilization of Treponems).
Treatment of syphilis is provided by penicillin antibiotics (bicillin, retarpen, extencillin)
in venerologic dispensary, according to the instructions of the Ukrainian Ministry of Health
Care.
Prophylactic measures: avoiding of extramarital relationships, using of condom. If
coitus was without condom or it has been torn, then the external genital organs should be
washed with soap and warm water, and during the first 2 hours the cleaning of genitals should
be performed.
AIDS
Agent of AIDS is retrovirus, which affect immune system of organism.There are two types
of Human immunodeficiency virus, that caused acguired immunodeficiency syndrome (AIDS):
HIV-1 and HIV-2.
HIV-1 is spread in all the countries of the world. HIV (human immunodeficiency virus)
is very sensitive to heating, while at boiling it dies immediately, as well as after applying of 70%
Ethanol, 0,2% solution of Natrii hypochlorate and other desinfective solution. But this virus
survives in its dried form during 4-6 days in 22°C temperature, in lower temperature even more.
The source of infection is the ill person or viral carrier. People with AIDS are infective all over the
life.The quantity of people with HIV in many times prevalents the quantity of ill person with
AIDS. Infected person becomes contagious in a very short time — 1 -2 weeks after infection.
The ways of infection:
• sexual, which insures natural viral transport from one person to another, as well as
sequel of homosexual contacts
• parenteral way of infection occurs when they break the sanitary rules making injections,
especially intravenous, when injections are made with one syringe, with changing only the needle
• professional way of infection of medical personnel occurs when blood of the person
with AIDS contacts with lesioned skin (microtrauma, fissure etc) or mucosal layer during
manipulations (injections and others)
• transfusional way occurs very rarely, when the infected blood is transfused to the
healthy person
• transplacental — from the infected mother to the child
So, HIV infection can be transmitted from people to people in direct contact: "blood to
blood" or "blood to sperm". Transmission of virus through saline during kissing is less possible.
The virus isn't transmitted by insect stings.
Clinical manifestations of AIDS: Incubation period can last from 1 month to 10
months or even to years. Clinical manifestations may vary, they can be divided into some
periods. In 30-50% of the inspected persons in 2-4 weeks an acute period can be observed:
fever, tonsillitis, enlarging of neck lymphatic nodes, liver, spleen. This lasts for 7-10 days, and
then the disease becomes latent. The only sign of illness at this time may be the enlarged
peripheral lymphatic nodes. They are movable, not connected with tissues, some of them are
painful at palpation. Such enlarging of the nodes can indicate to the AIDS, if it lasts for more
than 1,5-2 months. Later the so-called AIDS-associated or premorbid complex of symptoms
is developed. It can last from 1 to 6 months during some years. In this time many different
symptoms and diseases which are not specific for AIDS (up to 200) are developed. That is
the long-term fever, generalized enlarging of peripheral lymphatic nodes, periodical diarrhea,
weight loosing (more than 10%), oral cavity candidiasis, leukoplakia of tongue, folliculitis,
different skin lesions.
This period lasts wave-likely while health becomes better till the clinic remission,
when person considers himself absolutely healthy.
The last period is AIDS. In such persons different infectious diseases occur (up to 170)
on the base of immunodeficiency, caused by HIV-infection. Nervous system is damaged (in
30-90% of patients), poor orientation, bad memory and demention are develops.
Pneumocystic pneumonia (lung inflammation) occurs up to 60% with severe, sometimes with
fulminant passing. In 60% of cases severe and long-termed diarrhea is observed. Kaposhi's
sarcoma very often progresses and becomes the reason of death at young age In significant
part of patients having AIDS, malignant processes like lymphoma and others are developed as
a result of virus influence on immune mechanism of human being. Skin and mucosa are damaged
with Candida fungi (candidiasis, Herpes simplex and Circular herpes virus with severe, relapsing
duration, they don't undergo to usual methods of treatment.
Diagnosis. In AIDS the following diagnosis are mentioned:
• epidemiological history (homosexualism, drug abuse, prostitution, intravenous
injections etc.)
• a long-term enlargening of peripheral lymphatic nodes, loosing of body weight, long-
term fever and diarrhea
• revealing of antibodies to HIV in blood by immunofluorescent analysis and others. 5 ml
of venous blood is taken, and it is kept in refrigerator at the tempreature of+2 — +4°C. Serum is
taken out after appearing of the blood the clot and sent to the laboratory not later than in 1-3 days
Treatment. There are no medicines for treating AIDS. But remedies, that
inhibit development of the disease are used. Nowadays there is an effective
preparation for treatment of HIV infection and AIDS — Krixivan (protease inhibitor). Triple
therapy of Krixivan base (Krixivan+AZT+ZTS) has high effectiveness, decreases quantity of
viruses in blood to lower level. Immunostimu-lators, immunomodulators, symptomatic
therapy depending on the pathology is used.
Prophylaxis:
• sanitary and educational work among inhabits
• avoiding of pre- and extramatrial relationships
• using of condoms (decrease the transmission in 200-500 times)
• prophylaxis of drug abuse, parenteral (subcutaneous or intravenous) injectons of medicines
proper sterilization of medical instruments, using syringes and needles of single use
• using special defence agents by medical workers contacting with patients' blood and
other biological substances (special closes, double gloves, goggles, masks)
• control of donor blood
VIRAL DISEASES
The quantity of viral diseases of genital organs has been significantly inc-increasing for
the last time, especially among young people.
Viral infections can occur in latent form, with less symptoms and with expressed clinical
manifestation. That's why it is very difficult to diagnose them. These diseases have especially
negative influence on the pregnancy. There is a risk of viral transmission to fetus.
They can cause fetus diseases or defects of development, leading to fetus death or
miscarriage." Every pregnant woman with miscarried fetus must be examined on these
infections presence, because in the majority of such women Cytomegalovirus, Gripp virus,
Hepatitis A and В virus, Papillomavirus are revealed. Besides the influence on fetus, according to
the recent investigations, viral infection causes malignant growth in the female genital organs.
Herpesvirus infection
Herpesvirus diseases of genital organs are caused by Herpes simplex virus, mostly of the
second type (HSV-2). Source of the infection are infected persons and carriers. It may be
revealed in young sexually active women. It can be transmitted during orogenital contact. The
virus is located mostly in mucos membranes of urogenital tract in men and cervical canal in
women, also in the nervous ganglions of lumbar and sacral parts of sympathetic nervous system.
Genital herpes is transmitted sexually. During pregnancy it may cause miscarriage and
malformations.
Genital herpes is considered to be all-life persistant infection, that's why it has a relapsing
passing.
Clinical manifestations. According to the clinical signs, the disease duration is divided into
typical, non-typical, and asymptomatic one (viral carrier).
Typical passing of the disease is characterized by genital and extragenital signs.
Extragenital signs: rising tempreature, mialgias, headache, nausea, viral rash on face, bad
sleep. Genital signs are present on the lower parts of genital system — vulva, vagina, cervix,
near urethra os perineum. Single or plural vesicles up to 2-3 mm in size, with erythema and
edema, which exist for 2-3 days appear in mucous membranes. After vesicle rupture erosion
with incorrect form, covered with yellow discharge appears. The erosion re-epitheliazes
without scars in 2-4 weeks.
Patients complain of pain, irritation, itching in area with viral lesions.
Clinical manifestations are in three forms:
• I — acute primary
• II — chronic recurrent
• III — atypic
Depending on the localization, genital herpes is divided into three stages:
• the first one — herpes lesions of external genital organs
• the second — herpes lesions of the vagina, cervix, urethra
• the third — herpes lesions of the uterus, adnexa, bladder
Diagnosis is based on history taking, complaints, objective examination, revealing of
HSV-2 or its antibodies in the patient's serum.
The most informative method of identification is isolation of the virus from discharge
of the cervix, vagina, uterine cavity, urethra. For express-diagnosis a method of fluoriscine
antibodies and immunoperoxydase method are used. There is electro-microscopic method of
HSV-2 identification and the method of viruses inoculation on tissue culture with the
following studying of their properties.
Treatment is difficult because of the relapses of the disease and possibility of
reinfection.
Antiviral medicines belong to three main groups (according to the action
mechanism):
• replication inhibitors of viral nucleic acid
• interferon and compounds, that have interferon-inductive action
• compounds with other antiviral action
Difficulties of treatment are caused by virus peculiarities (they are obligate
intracellular parasites).
As a result of investigation of virus nature on molecular level, new medicines were
created. They have the influence on viral growth and development of the virus. They are
Zovirax (Acyclovir, Valacyclovir), Alpizarin, Foscarnet, Valtrex, Herpevir. Acyclovir is used
in dose of 600-1200 mg per day, orally or intravenously.
Local therapy by 3% Megasin ointment, 3% Bonaphton or 3% Alpizarin is also used.
For treatment of the recurrent herpes antiviral medicines, herpal vaccines, antirecidive
immunotherapy are used.
Condylomas acuminata
Ethiology. Condylomas acuminata are caused by Human Papillomavirus of 16 and 18
types. They are transmitted sexually (fig. 98). Resistant to disinfective agents viruses may be killed
by high temperature during sterilization. Incubational period of condyloma acuminata lasts from 1 to
9 months. The disease often occurs in sexually active persons. Papillomavirus causes genital
cancer. These patients have in 1-2 thousands times more chances to acquire a malignant process,
than healthy people. Condylomas acuminata can transform into cancer in 6-26% of cases.
Clinical manifestations: On the onset of disease single pink, sometimes grey warts,
with thin pedicle, rarely with wide base appears on skin surface of labia majora, perineal area
and mucosal layer of urethra, anus, vagina, cervix. Condylomas acuminatum can grow
significantly and fuse (fig. 99). They looks like cauliflower, with lobular structure, and have
long-term duration. Some patients with long-term duration of the process can have big
condylomas, like tumor. They can be complicated by abnormal vaginal discharge, due to the
secondary vaginal infection. Condylomas may cause some difficulties at walking, intercourse.
During pregnancy and delivery they can cause bleeding. In 15-17% of patients regression
may occur, especially during pregnancy.
Clinical diagnosis. Lobular surface, soft consistency, thin pedicle should be taken
into consideration.
Differential diagnosis for genital warts includes condylomata latum, which have wide
base, brown or red colour, and no lobular structure. Also other manifestations of syphilis are
present there.
Treatment If genital warts are large, laser vaporization is performed. It is more
effective, than criodestruction or surgical diathermy. For treatment of small condylomas 30%
solution of Podophyllin, Condilin or Resorcin are used. Modern effective remedy is Solcoderm.
Molluscum contagiosum
Ethiology. Molluscum contagiosum is caused by virus, that is transmitted by contact
with the ill persons or during using their things. In adults the main way of transmission is
sexual contact. Children are infected more often. Incubation period lasts from 2 till 9 months.
Clinical manifestations. On skin the small firm dome-shaped papules 5-7 mm in
diameter, occasionally enlarging to 1-3 cm conglomerates is appeared. The flesh-colored
papules have specific central umbilication (fig. 100). Lesions are located on the external
genital organs, perineum, pubis, hips, face.
Molluscum contagiosum can persist for a long time.
Clinical diagnosis. After direct pressure by forceps white caseous material can be got.
Treatment. The lesions are pressed by forceps and cleaned by Iodine solution or
Betadine, garlic juice or cryotherapy.
Cytomegalovirus infection
Infectional agent is Human cytomegalovirus. The percentage of the infected women
according to the world literature is very high. In Western Europe it is from 50 to 85%. Among
pregnant women with usual miscarriage 70% are infected.
Fig. 100. Molluscum contagiosum (histological picture)

After invasion cytomegalovirus persists in organism for a long time, spreading by saline
and sexual contacts.
Clinical manifestations. The main signs of the infection are extragenital symptoms:
CNS-lesions, thrombocytopenia, liver disorders, pneumonia. Infecting of the fetus during pregnancy
leads to intrauterine development defects (microcep-falus, deafness), diseases of the newborn
(cerebral paralysis, miasthenia). It is manifested by cervicitis, cervical erosions, vaginitis,
vulvitis and other inflammatory diseases, that have subclinical passing.
Diagnosis: Blood and urine tests for virus presence are performed. Cytoscope analysis of
saline and urine sediments are based on the properties of Cytomegalovirus to penetrate into the
cells and to make big intranuclear inclusions. Infected cell becomes bigger, it is the so-called
cytomegalovirus cell, "an owl's eye".
Serological methods: indication of antibodies components to HCMV (1:8 and more is
considered to be positive).
Non-direct immunofluoriescence method and DNA-diagnostics (chain polymerize
reaction) are used.
Treatment. The main purpose is the correction of the immune system disorders.
Preparations for immunity stimulation (Levamizol, T-activin, Immunoglobulin, Ginseng tincture)
are used. Application of ointment and injection of leukocyte interferon, immunoglobulin with high
titred cytomegalovirus antibodies ("Citotect") into cervix are used. Wide spectrum of antiviral
preparations (Valtrex, Acyclovir, Ribavirin, Gancyclovir, Bonaphton) are less effective.
Prophylaxis. Avoiding of pre- and extramarital sexual contacts, using of condom,
keeping the rules of personal hygiene.
Tuberculosis of genital organs

Genital tuberculosis is the secondary disease. Very often clinical focus is in lungs. The
disease is caused by Mycobacteria tuberculosis, which is transmitted hematogenically from lungs
or intestine to genital organs. Mostly women from 20 to 40 years of age become ill.
Tuberculosis infection is found in 5-8% of patients with inflammatory diseases of genital
organs, and in 1-3% of patients with salpongoophoritis.
Mycobacteria tuberculosis contaminate into genital organs mostly in childhood, but
clinical manifestations appear in the pubertyperiod, with the beginning of sexual life and after
supercooling.
Tuberculosis damages uterine tubes (85-90%), rarely uterus and ovaries (fig. 101, 102), and
more rarely — the cervix, vagina, external genital organs.
According to Aburela E. and Petersuc B. (1975) classification, there are four main forms
of specific process in the female genital organs:
• tuberculosis of genital organs with microdamages mostly with productive character,
and latent duration
tuberculosis of genital organs with macrodamages mostly with exudative-proliferative or
caseous character, and lasts like salpingoophoritis and endometritis, accompanying with ascites or
adhesive peritonitis
• associative tuberculosis of genital organs and tuberculosis of other organs (lungs,

kidneys) or tuberculosis of genital organs, combined with the other gynecological diseases
(endometriosis, sclerocystic ovaries, uterine myoma)
• clinically curable genital tuberculosis with posttuberculosis changes (petrification,
adhesions, degeneration)
Fig. 102. Tuberculisis of uterus, fallopian tubes, ovaries, parametrial tissue
Pathomorphological examination reveals inflammatory changes. Morphological specificity

of them is in presence of tuberculous granuloma in productive phase of inflammation a focus of
caseous decomposition with exudative phase of the process. If antituberculosis medecines are
used in exudative inflammation phase, the exudate resolves with complete or almost complete
renewing of tissue structure. Destruction of the tissue is substituted by the connective tissue in
productive phase of the process. Separation of the focus from intact tissue take place in case of
caseous damage resolvation of perifocal infiltration and fibrose transformation of the destruction
zone with the capsule. In such focus Mycobacterium tuberculosis can stay for a long time and in
some cases it causes relapsing.
Clinical manifestation. At "small" forms of tuberculosis pain syndrome is absent.
Dominant sign may be menstrual dysfunction (hypomenorrhea or algo-dysmenorrhea). Pain
appears in case of large damage. Almost all the patients with genital tuberculosis suffer from
reproductive disorders, i.e. primary or secondary infertility, ectopic pregnancy.
If the changes in endometrium are significant, amenorrhea (uterine form) can develop.
General changes in the patient's organism are accompanied by the signs of tuberculosis
intoxication: disorders of general state, weakness, sweating, sub-febrile temperature.
Diagnosis. Diagnosis is based on the history data (contact with tuberculosis patients,
previous tuberculosis of bones, lungs, bronchitis, pneumonia, long-lasting subfebrile
condition), objective examination (tuberculosis changes in organs or their sequel),
bacteriological examination, additional methods of examination, including histological. For
confirming the diagnosis of tuberculosis special tests are used (Mantu, Koch's). The Mantu test
identifies only the specific sensitization of the patient and has less diagnostic value. For
diagnosis the Koch's test is important. General, local and focal reactions appear after
subcutaneous injection of 20 IU of tuberculin in patients with tuberculosis. General one is
manifested by high temperature, headache, weakness. Focal reaction manifests itself in 48-72
hours by enlarging of adnexal infiltration, they become more painful.
The Koch's test can be confirmed by changes in hemogram (high quantity of
leukocytes at the expence of the low amount of monocytes, eosinophiles and lymphocytes),
proteinogram (low amount of albumin and high amount of glo-bulines), immunogram. C-
reactive protein and high level of sialic acid appear in blood.
Bacteriological method is very important, it is in revealing of Mycobacterium
tuberculosis in uterine and adnexal tissue. Material for inoculation is discharge from uterus
and vagina, punctate from ovarian tumor or tissues taken during laparoscopy.
Laparoscopy is a valuable method, it allows to perform visual examination of
abdominal cavity and to take tissual samples for bacteriological and histological analysis.
roentgenological examination of genital organs and thoracic cavity are necessary,
especially in patients with first manifestations of the process in the uterus or adnexa (fig.
103). Hysterosalpingography allows to estimate uterine cavity state, uterine tubes, their
permeability and other changes, caused by tuberculosis.
Histological examination of endometrium after uterine cavity curettage is important,
too.
Ultrasonic echography for estimation of morphological changes in uterus and its
adnexa is also used.
Treatment of genital tuberculosis is complex and includes rational regimen,
dietotherapy, vitamins, symptomatic therapy and climatic health-resort cure.
The main is the antibiotic therapy. Antituberculosis agents, being in nse now, are:
Rifampicin, PAS A, Ethambutol, preparations of Izonicotine acid. For preventing
mycobacterium persistation, combination of remedies (Izoniazide + Rifampicin) are used. If the
process is revealed for the first time, or it has acute or subacute passing, three preparations are
prescribed: antibiotic, one preparation
Fig. 103. Calcificates in tuberculosis
of Izonicotine acid (Izoniazide, Saluzid) and PASA. The last one has not only
bacteriostatic action, but also prevents from development of microorganisms resistention to
antibiotics and preparations of izonicotine acid, that's why they can be used for a long time.
Treatment lasts for 1,5-2 years, during the first 3-6 months the combination of 3 medicines is
used, and later on for 6-8 months 2 agents are taken. After that supportive therapy is performed
till 2 years.
Intramuscular and oral usage of medicines are combined with injection of some dose of
medicine in focus of lesion. Lidase with antibiotics and hydrocortisone are used for this purpose
by means of colpocentesis to the damaged organ. These medicines may be used during
hydrotubations. 1 % solution of chimo-tripsin is used through posterior fornix and by
electrophoresis. In some cases surgical treatment is used. In spring and autumn antirecidive therapy
is performed.
Rehabilitation of such patients is provided in specialized health resorts (Odessa,
Alupka). For resolvation of residual affects after tuberculosis physiotherapy and pelotherapy are
used.
Assignments for Self – assessment.
II. Multiple Choise.

Choose the correct answer / statement
1. The most freguent type of inflammatory diseases is:
A. Iron-deficiency amenia;
B. Folate-deficiency amenia;
C. Pain;
2. Which of the following is Not characteristic of inflammatory diseases?
A. Decreased factor VII;
B. Pain;
C. Family history of the diseases;
D. Prolonged bleeding time.
3. Infants bom to mother with inflammatory diseases are at higher risk for:
A. Neonatal patology;
B. Neonatal hypoglycemia;
C. Hypoglycemia;
D. Polycythemia.
III.Answers to the Self- Assessment.1.C, 2.A, 3.A.
References:
412.

4 course

FAMILY PLANNING
TOPIC 7. "ACUTE ABDOMEN" IN GYNECOLOGY

Emergency surgery is one of the most actual problems of practical medicine. The
quality of surgical aid at acute diseases in obstetrics and gynecology depends on timely
diagnostics.
II. Aim:
- Ectopic pregnancy, clinical manifestations, diagnosis, tactics. Emergency aid.
- Apoplexy ovary, clinical manifestations, diagnosis, tactics. Emergency aid.
- Ovarian tumor capsule rupture, clinical manifestations, diagnosis, tactics. Emergency aid.
- Torsion stem tumor, clinical manifestations, diagnosis, tactics. Emergency aid.
- Preoperative preparation and postoperative management of gynecological patients.
Anesthesia during gynecological operations. Rehabilitation after gynecological surgery.
- Collect special gynecological history, assess the results of laboratory studies (general and
biochemical analyzes of blood, urine, blood coagulation system, etc.). In emergency
conditions in gynecology
- Gynecological studies (mirror, bimanual, rectal, rectovaginal) in emergency conditions in
gynecology
- Puncture the abdominal cavity through the rear arch (phantom).
- Evaluate the results of ultrasound in emergency conditions in gynecology
- To make a table in the differential diagnosis of ectopic pregnancy, ovarian apoplexy,
torsion leg tumor necrosis myoma node.
- Principles of laparoscopy in emergency conditions in gynecology
- Preoperative preparation and postoperative gynecological patients their driving.
ECTOPIC PREGNANCY
Pregnancy is called ectopic when it fertilized ovum implants outside the borders of
uterine cavity.
Ectopic is one of the most serious gynecological diseases, because its interruption is
followed by considerable intraperitoneal bleeding and needs emergency service.
Etiology. Anatomic changes in tissues of uterine tube that appear in the result of
inflammatory processes are the main causes of the violation of ovum transport and ectopic
pregnancy. Inflammation of mucous membrane, its edema and presence of inflammatory exudate
in acute and chronic stages may cause dysfunction of uterine tubes. After this adhesions and
closing of ampular end of the tube are formed. Damaging of muscular layer and changes in
innervation of the tube lead to changes of its peristalsis and delay of fertilized ovum passing
through it. Considerable anatomic changes in tubal layer or adjacent tissues cause abortions,
operative interventions into the organs of true pelvis. Ectopic pregnancy frequently happens in
women with genital infantilism, endometriosis, tumor of the uterus and uterine adnexa. Usage of
intrauterine contraceptives increases the risk of ectopic pregnancy. There are scientific datas that
toxic influence of exudate in tube at its chronic inflammation causes speed-up trophoblast
maturing, that's why the proteolitic enzymes activize, and implantation comes before fertilized
ovum enters the uterus. In case of the slow development of trophoblast an ovum is implanted in
lower uterine (placenta praevia) segments or outside uterine cavity - in its cervix (cervical
pregnancy).
Classification of ectopic pregnancy. Depending on that, where a fertilized ovum has
implanted tubal pregnancy, ovarian pregnancy, abdominal pregnancy, pregnancy in rudimentary
uterine horn, intraligamentaory (between folds of wide uterine ligament) and cervical pregnancy
are distinguished.
In majority of cases (98,5 %) the tubal pregnancy occurs. Interstitial pregnancy happens
in interstitial portion of tube, isthmic - in isthmus and ampullar - in ampullar portion. According
to clinical duration unruptured and interrupting ectopic pregnancy are distinguished. Interrupting
of ectopic pregnancy happens by type of tubal abortion or by type of uterine tube rupture.
Duration of ectopic pregnancy. After implantation of fertilized ovum in woman's
organism there appear changes, typical for normal uterine pregnancy: yellow pregnancy body is
developed in ovary, decidual membrane is generated in uterine, uterus becomes soft and enlarges
under the influence of ovarian hormones. All these signs are typical for pregnancy. The chorionic
gonadotropin is also produced. One can find gonadotropin by means of appropriate researches.
Pregnancy test is positive. Women have presumptine pregnancy signs: nausea, appetite changes
and so on.
A fertilized ovum, that has been implanted into endosalpinx, goes over the same
development stages, as in case of uterine pregnancy. The chorion villi are generated. At first they
grow into mucous layer of the tube, then, without finding sufficient conditions for development,
they grow into its muscular layer. While the size of fertilized ovum increases, the walls of tube
stretch. The chorion villi, invading deeper, bring on its destruction. A layer of fibrinoid necrosis
is generated. For Werth's figure of speech, "a fertilized ovule digs in tube wall not only nest for
oneself, but the grave". The wall of uterine tube can not create favourable conditions for fetal
development, that's why within 4-7 weeks interrupting of ectopic pregnancy takes place.
Tubal pregnancy is interrupted for type of uterine tubal rupture or for type of tubal
abortion, depending on the method the embryo is going out into abdominal cavity. In case of
rupture of uterine tube destruction of its wall takes place in the result not of mechanical tension
and rupture, but in the result of corrosion by chorion villi. At pregnancy interrupting for type of
tubal abortion exfoliating of the embryo from tube walls and its passing into abdominal cavity
through the ampular end takes place.
Unruptured ectopic pregnancy
Difficulty of diagnosis is connected with absence of symptoms which differ ectopic
pregnancy from the uterine one. Sometimes women can feel uterine pain in the 'ower part of
abdomen. During bimanual research one can palpate the enlarged tube, but sometimes it is not
possible to do that because only at the end of the second month the tube reaches the size of an
ovum and soft elastic consistence gives no possibility to palpate it distinctly. A differential
diagnosis of unruptured ectopic pregnancy is made in case of uterine pregnancy of early terms,
cyst, ovary cystoma and hydrosalpinx.
Elastic organ is palpated in case of either ovarian cystoma near the uterine or in case of
unruptured tubal pregnancy, in which uterus is not enlarged, reaction to the chorionic
gonadotropin (CG) is negative. There is no ischomenia. .;
In case of hydrosalpinx in adnexal region elastic organ is also found, but uterine is not
enlarged, women do not complain on ischomenia, reaction on CG is negative.
Diagnosis difficulties appear owing that uterus continues to enlarge because of the
development of decidual envelope and hypertrophy of mucose fibres, but uterus falls behind in
dimensions typical for the certain pregnancy term.
Tests for chorionical gonadotropin" determination in such cases give a possibility to
establish the pregnancy presence, but they don't give answer to the question about its
localization. In some cases one can make diagnosis of unruptured ectopic pregnancy with
ultrasonic research. In this case embryo is absent in uterine cavity. The diagnosis can be
confirmed by means of laparoscopy Urgent hospitalization for complex examination and
supervision is necessary in case when there is suspicion for unruptured ectopic pregnancy. The
patient has to stay under the careful supervision of medical personnel. One should inform a
doctor in case when there appear some changes in woman's state, especially when there are the
symptoms typical for internal bleeding.
After entering stationary it is necessary to define blood type, and also rhesus-factor of the
patient immediately.
Tubal abortion
Clinic. In case of tubal abortion exfoliating of an embryo from tube wall
and its passing into abdominal cavity take place. The clinic of tubal abortion is
displayed by colicky pain, that is localized in one of iliac parts and irradiates into thigh, rectum
and sacrum. Sometimes pain appears in supraclavicular part - frenicus-symptom. If embryo
drives out from the tube at once, sometimes it is followed by considerable bleeding, giddiness
and loosing of consciousness. Sometimes exfoliating of embryo ceases for a while, pain stops
disturbing, however the pain is soon renewed. This can repeat once or twice, then the tubal
abortion lasts for a long time. Blood, that outflow from the tube, accumulates in cul-de-sac and
causes the feeling of pressure on rectum.
Diagnosis. The diagnosis of tubal abortion is not very simple. Carefully studied past
history is of a great importence. Doubtful and probable signs of pregnancy are present.
Anaemia'is common due to intensive blood loss, arterial pressure decreases abruptly and pulse
accelerates. Abdomen is flatulent, its participation in breathing act is limited. In lateral
abdominal parts blunting percussion sound is determined, during palpation there are the
symptoms of peritoneal irritation.
During speculum examination is revealed cyanosis of vaginal mucosa and uterine cervix,
typical are the secretions, described previously. At bimanual examination one can find that
uterus is enlarged, but it does not correspond to menstruation delay term, isthmus allotment is
soft, cervix motions are painful. In adnexa region from one side one can palpate an organ of
elastic consistence with unclear contours. Back vault is smoothened or even prominent.
Differential diagnosis of tubal abortion. In the cases, when there is no considerable
intraperitoneal bleeding, tubal abortion should be differentiated with uterine abortion in early
term, exacerbation of salpingo-oophoritis, dysfunctional uterine bleeding and cystoma crus
torsion.
At uterine abortion there is a permanent colicky pain, that irradiates into lumbar part.
Discharge is bright or dark red coloured.
At tubal abortion pain is periodic, colicky, ordinarily it is followed by dizziness, and
irradiates into rectum.
When percussion blunting of sound in lateral part of the abdomen is found in ectopic
pregnancy and tympan is in case of uterine abortion.
Secretions from vagina in tubal abortion appear after pain attact, they are dark, of poor
amount, in case of uterine abortion they are bright red and considerable.
General woman's state in tubal abortion does not correspond to external hemorrhage, but
in uterine abortion it does. Bimanual examination in case of tubal abortion gives a possibility to
find a formation nearby the uterus, uterus does not correspond to pregnancy term, whereas in
case of uterine abortion uterine size correspond to pregnancy term and ovaries are not altered.
There are some differences between the inflammatory process of uterine adnexa and tubal
abortion. In case of inflammatory process there are no menses delays, reaction on CG is
negative. Unlike tubal abortion pain during this disease appears gradually, there is no dizziness.
Pain is not colicky, but permanent.
In case of tubal abortion with a long abortion duration one can observe subfebryle
temperature, whereas in case of acute uterine adnexa inflammation temperature is high in most
cases. Some blood loss at tubal abortion gives rise to BP lowering, in inflammatory process BP
is normal. In case of abortion pulse is higher, temperature rises rarely.
In case of tubal abortion abdomen is slightly flatulent, but soft and painful during
palpation on one side, during percussion blunting sound is observed in lateral departments. In
case of inflammatory process examination of abdomen gives the identical symptoms, however
there is no blunting of percussion sound.
Bloody secretions in inflammatory processes of ovaries can be rarely found. Unlike the
secretions of tubal abortion, they are bright, sometimes with purulent admixtures.
During bimanual examination enlargement of uterus with unclear adnexa contours from
one side testifies about tubal abortion rather than about inflammation of ovaries, in which uterus
is not enlarged and ovaries are palpated as enlarged from both sides. Often in tubal abortion
sagging of back vault is found.
In spite of great amount of differences, which give a possibility to make a differential
diagnosis between tubal abortion and inflammatory process of ovaries, sometimes it is very hard
to distinguish them. US and specially culdocentesis are importent in such case. In case of tubal
abortion during puncture blood is received and in inflammatory processes one can get serous or a
purulent liquid.
If one couldn't manage to specify diagnosis and the general woman's state is satisfactory,
they hold on resolvent and hemostatic therapy during 5-7 days with careful clinical supervision.
In tubal abortion all phenomena (colicky character of pain, bloody secretions) progress and at
inflammatory process improvement of general state is observed.
Tubal abortion differs from cystoma crus torsion. In case of cystoma torsion there is no
menses delay, reaction on chorionic gonadotropic is negative, bloody discharge and signs of
internal bleeding are absent. Cystoma torsion is found by abdomen palpation. US and sometimes
endoscopy is used as individual method.
Differential diagnosis between tubal abortion and appendicitis. In appendicitis a patient
does not complain of menses delay, there are no signs of pregnancy. At tubal abortion pain is
periodic, colicky, with one side localization. In appendicitis it apears at first in epigastria, and
lateral then it localizes in right iliac region and it is accompanied by nausea and vomiting, that
are rare in case of tubal abortion. Bloody excretions and signs of internal bleeding are absent.
Palpation of the abdomen in acute appendicitis expresses tensity of the front abdomen, whereas
in case of tubal abortion it is insignificant and sometimes it is absent. The Schotkin-Blumberg's
and Rovzing signs testifies acute appendicitis while frenicus-symptom is absent. During
bimanual examination in case of acute appendicitis uterus and ovaries are not enlarged. If much
time has passed since the beginning of the disease, one can not always palpate them because of
irritation of pelvic peritoneum. An infiltrate is palpated above and it is not possible to reach it
through vagina.
A blood analysis in case of appendicitis gives leucocytosis with shift to the left, there is
no anemia, whereas at tubal abortion blood picture is typical for anemia. After all, a
culdocentesis can be a diagnostic criterion.
When clear differentiation is impossible, it is necessary to make laparotomy.
Tubal rupture
Clinic. Tube rupture develops more frequently in that case, when pregnancy
is localized in isthmus or interstitial department. Clinics displays by severe internal
bleeding, shock and acute anaemia.
Disease begins after menses delay with acute pain in lower abdomen, which appears
suddenly. It is localized in iliac areas and irradiates into rectum and sacrum. This pain is
followed by momentary loosing consciousness. After this patient remains adynamic. During the
attempt to get up she can lose her consciousness again.
Patient has all signs typical for internal bleeding: acute pallor, cold sweat, coldness of
lower limbs, feeling of weakness, sometimes there is a threadlike pulse. The abdomen is
flatulent, its participation in breathing act is limited. There is blurting of percussion sound in
lateral abdominal region. Palpation of the abdomen is very painful. There are signs of peritoneal
irritation.
Diagnosis. During .speculum examination cyanosis of mucous membrane of vagina is
found. Bloody excretions are present, though not always. They are dark-coloured and look like
coffee-grounds.
At bimanual examination cervical motion is always painful, there appears bulging and
acute pain of the posterior pouch. Uterus body is enlarged insignificantly and along its side
painful organ with unclear contours can be palpated, sometimes it is pulsatory. One should
remember, that it is not always possible to palpate uterus and ovaries because of acute pain
during gynecological examination.
Following signs can help in diagnosis of ectopic pregnancy:
" Laffon 's sign - consecutive shift of pain feelings: at first in suprabrachial part,
then shoulder, then pain spreads into back part, scapulars, under sternum
" Elecker 's sign - abdominal-ache presence, that is followed by its irradiation into
shoulder and scapulars on tubal rupture side
" Gertsfield s sign - urging to urination appears during tubal rupture moment
" Kulenkampf's sign - intensive pain during percussion of anterior abdomenal wall
At vaginal research such signs are determined:
" Landau's sign - intensive pain during speculum or fingers inserting into vagina
" Golden' s sign - uterine cervix pallor
" Bolt' s symptom - acute pain during an attempt to displace uterine cervix
Gudell' s sign - soft consistence of cervix
" Promptov 's sign - woman feels acute pain during an attempt to displace uterus up
by inserted into vagina and rectum fingers. At appendicitis examination per rectum causes pain
in rectouterine pouch
" Goffman 's sign - uterus displacement into contrary from altered tubal side.
During examination uterus easily comes into normal position, and when examination is over it
returns into its previous position
At long blood presence in abdominal cavity its partial resorbtion takes place and
transformed bilirubin deposits in skin cells. That's why there appear such signs:
" Gofshteter' s sign - presence of blue-green or blue-black colouring of skin in navel
region
" Kuschtalov s sign - yellow skin colouring of palms and soles, specially in fingers
area
Diagnosis:
" history taking
" physical examination with typical symptoms
" pelvic examination
" test on pregnancy
" ultrasonic diagnostics
" culdocentesis
" in complicated cases culdoscopy or laparoscopy are performed
Rare forms of ectopic pregnancy
Ovarian pregnancy, intraligamentous pregnancy, abdominal pregnancy, cervical
pregnancy and pregnancy in rudimentary uterine horn belong to the rare forms of ectopic
pregnancy.
Ovarian pregnancy. At such localization pregnancy develops either in fc .acle (follicular
pregnancy), or upon the ovarian surface. Progressing of pregnancy is followed by pain,
peritoneum tension, that covers an ovary. Interrupting comes in early terms. In rare cases
pregnancy can reach late terms.
Abdominal pregnancy is primary and secondary. At primary one fertilized ovum is
implanted immediately in abdominal cavity - on peritoneum, omentum, bowels, liver. Secondary
abdominal pregnancy develops as a result of reimplantation of fertilized egg in cavity of small
pelvis after proceeding from uterine tube by reason of tubal abortion. Abdominal pregnancy can
be interrupted in early terms, bringing the picture of acute abdomen, but sometimes it can reach
the late terms. A fetus is palpated right under the abdominal wall, its heart beat is clearly
auscultated, enlarged uterus is determined separately from the fetus. In-term birth of living child
is possible! Operation is in fetus and placenta removal but there appear considerable technical
difficulties with compartment of placenta from internal organs.
Intraligamentorus pregnancy. If tubal pregnancy, chorion villi don't grow into the
abdominal cavity, but into side of broad ligament of the uterus, separating it, embryo comes into
space between leaves oflig. latum uteri and continues to develop between them. Embryo,
protected by leaves of the broad ligament, can develop to late terms or even to full-term,
however more frequently interruption of such pregnancy in 2-3 months term takes place. At its
interrupting a big haematoma accumulates, and if the leaves of the broad ligament are ruined in
the result of chorion villi penetrating, bleeding into abdominal cavity can appear.
Pregnancy in rudimentary uterine horn. The rudimentary uterine horn can have junction
with the cavity. In that case impregnated ovum is able to come there. Progressing pregnancy
doesn't give special symptomatics. During palpation a tumor-like organ, adjacent to uterus is
determined, sometimes on a cms. It is mobile and painless. Muscular layer of rudimentary horn
is developed insufficiently as compared with miometrium, but it is developed much better in
comparison with the uterine tube, that's why pregnancy in rudimentary horn is interrupted in later
terms. Bleeding at such localization of ectopic pregnancy is considerable, that's why quick
transportation of a woman into medical establishment is necessary. Diagnosis and operation are
of particular importance.
Treatment. Just after confirming the diagnosis decision about operative treatment is
taken. During hospitalization into stationary patients blood type and rhesus-factor is immediately
determined, so that one can stop blood loss and shock. Amount of transfused blood is determined
according blood loss and general state of a patient.
The altered uterine tube is removed during the operation. Conservative-plastic operations
are made recently for saving of reproductive function of women. In absence of expressed
anatomic changes in tube and at satisfactory woman's state embryo is removed from the tube, the
tube is sutured. If pregnancy interrupting took place not long ago, blood is not hemolized, and
there is a necessity for immediate blood transfusion. The blood, taken from abdominal cavity
may be reinfused.
Ovarian apoplexy is blood effusion into ovary parenchyma, which is followed by
bleeding into abdominal cavity.
Apoplexy causes are not clearly determined. It can develop in any day of ovarian-
menstrual cycle or after menses delay, but more frequently it can happen in the middle of the
cycle. The provoking factors are sexual act, trauma of the abdomen, operative intervention,
mechanical pressing of the vessels by pelvis tumor.
Clinic. Disease begins suddenly, with pain frequently in one of the iliac region, which
often spreads through the abdomen and irradiates into rectum, inguinal areas, sacrum and legs.
The symptoms of internal bleeding appear, shock with loss of consciousness is common. The
body temperature is normal. During abdominal palpation it is flatulent, patient can feel pain in
lower abdomen in one or both sides.
Diagnosis. Previous diagnosis is made on the basis of carefully taken anamnesis and
complaints. Disease onset data of physical and also vaginal examination are taken into
consideration.
Bimanual research gives a possibility to set gynecological nature of the disease. Bulding
(in case of severe bleeding) and pain of vaginal fornixes is present. Displacement of cervix
causes strong pain. Uterus is of normal size, and pain is determined in ovaries region from one
side. There is enlarged, cystically changed ovary.
Frequently at apoplexy a diagnosis of ectopic pregnancy is made, because there are no
symptoms, typical for apoplexy.
Differential diagnostics is made with ectopic pregnancy and appendicitis. It is necessary
because at ectopic pregnancy operative intervention is obligatory, while a apoplexy - not always.
During differential diagnostics of ovary apoplexy with ectopic pregnancy one must pay attention
to the fact that at apoplexy there are not signs of pregnancy. More frequently ectopic pregnancy
appears after menses delay (not always!). Pain in both cases appears abruptly, irradiates into the
same areas. In ectopic pregnancy frenicus-symptom is expressed, while apoplexy it happens
rarely.
In apoplexy the peritoneal irritation phenomena and symptoms of internal bleeding are
not so clearly expressed. However there are no clear criterions, for which one can distinguish
ovarian apoplexy from interrupted ectopic pregnancy, especially if it interrupts by tubal rupture
type. That's why management has to be determined by patient's general state.
As for differential diagnostics with acute appendicitis, one must remember, that in
appendicitis more frequently pain initiate at the epigastric region, there are nausea and vomiting
and no signs of internal bleeding. At abdominal examination muscular defancel and positive
Schotkin-Blumberg's symptom are observed.
Treatment. At absence of expressed signs of internal bleeding a conservative cure can be
applied. We put a cold thind on abdomen, hold haemostatics. After fading of acute phenomena
physiotherapy is prescribed.
In case of expressed internal bleeding an operative intervention is indicated. Its volume
depends upon the changes which take place in ovaries. If there is a big haematoma, and ovarian
tissue is completely blasted by effusions of blood, it should be removed. In case of small
haematoma an ovary resection is made.
1. Etiology, pathogenesis and classification of extrauterine pregnancy.
2. Clinical signs of progressing extrauterine pregnancy and the methods of
its diagnostics.
3. Clinical signs of interrupted extrauterine pregnancy and the methods of its
diagnostics.
4. Clinical differences of extrauterine pregnancy interrupted by the rupture of
the uterine tube and tubular abortion.
5. Differentiation diagnostics of extrauterine pregnancy and acute
appendicitis.
6. Methods of surgical treatment of extrauterine pregnancy.
7. Indications for concervative treatment of tubular pregnancy.
8. Methods of concervative treatment of tubular pregnancy.
9. Cervical pregnancy. Diagnostics and treatment.
1. A 31- year- old patient is admitted in the gynecological department

complaining of severe blood discharge from the genitals, weakness, and dizziness. She
experienced measles, parotitis flu, frequent quinsy. Menstrual cycle is not regular,
starting from the age of 12. She became sick 15 days ago, when blood discharge
appeared from the genitals after 2 months of delay. The following days intensity of
bleeding increased, weakness and dizziness developed. A general condition is of
moderate severity. Pulse is 90. BP- 80/70, mercury. The tongue is moist and clean. The
patient is of an average fatness, the mammary glands are poorly developed. Heart or lung
pathology is not found. Blood analysis: haemolobin- 50g/l, erythrocytes- 2200000.
Rectal-abdominal examination: smooth and conical cervix, uterine body is in the normal
position, small, mobile, painless. The adnexa are not detected on the both sides. Blood
discharge with clots.
Diagnosis. Plan of treatment. Measures concerning prevention of uterine
bleeding.

References
412.

4 course

FAMILY PLANNING
TOPIC 8. "ACUTE ABDOMEN" IN GYNECOLOGY
Amount of hours:2 hours in practical classes

Emergency surgery is one of the most actual problems of practical medicine. The
quality of surgical aid at acute diseases in obstetrics and gynecology depends on timely
diagnostics.
II. Aim:
- Ectopic pregnancy, clinical manifestations, diagnosis, tactics. Emergency aid.
- Apoplexy ovary, clinical manifestations, diagnosis, tactics. Emergency aid.
- Ovarian tumor capsule rupture, clinical manifestations, diagnosis, tactics. Emergency aid.
- Torsion stem tumor, clinical manifestations, diagnosis, tactics. Emergency aid.
- Preoperative preparation and postoperative management of gynecological patients.
Anesthesia during gynecological operations. Rehabilitation after gynecological surgery.
- Collect special gynecological history, assess the results of laboratory studies (general and
biochemical analyzes of blood, urine, blood coagulation system, etc.). In emergency
conditions in gynecology
- Gynecological studies (mirror, bimanual, rectal, rectovaginal) in emergency conditions in
gynecology
- Puncture the abdominal cavity through the rear arch (phantom).
- Evaluate the results of ultrasound in emergency conditions in gynecology
- To make a table in the differential diagnosis of ectopic pregnancy, ovarian apoplexy,
torsion leg tumor necrosis myoma node.
- Principles of laparoscopy in emergency conditions in gynecology
- Preoperative preparation and postoperative gynecological patients their driving.
PYOSALPINX RUPTURE
An abscess rupture takes place spontaneously or in the result of physical trauma.
Clinic. Before abscess perforation there is always patient's health change to the worse -
pain reinforces, temperature rises, peritoneum irritation symptoms are intensifying. Just after
rupture there appears an acute pain which has a cutting character through the abdomen, collapse,
nausea, vomiting, stomach is strained and strongly painful. General patient's state becomes
worse, the face features sharpen, breathing becomes frequent and superficial. In the result of
bowels paresis abdomen becomes flatulent, peristalsis disappears and meteorism develops.
Diagnosis. During stomach percussion one can find blunting of sound in lateral
departments because of exudate presence in abdominal cavity.
During bimanual examination uterus and ovaries palpation is impossible because of acute
pain and tension of front abdominal wall and vaginal fornixes bulgeng. Pelvic peritonitis may
develop in the result of pyosalpinx rupture. Specification of the diagnosis can be made by means
of ultrasonic research and culdocentesis.
Treatment. Cure of patients with purulent process in abdominal cavity is a complicated
problem, successful solving of which needs fast and decisive actions. Operative cure with
ablating of altered ovaries and following drainage of abdominal cavity is necessary. Laparotomy
should be made by lower-middle incision, because this access gives a possibility to make a
revision of abdominal cavity organs and its wide drainage, and if it is necessary - peritoneal
dialysis. During the operation it is necessary examine appendix because its frequent involving in
pathological process. If pathological changes are found appendectomy is done. Removal of
purulent mass is technically difficult and needs caution and carefulness, but ablating of purulent
formation is obligatory, because drainage, without ablating causes formation of purulent fistulas,
those do not heal for a long time. A conservative care of such patients (antibiotics, vitamin
therapy, cold on umbilicus) can give a temporary state improvement, but not a convalescence.
Disease acquires chronic recidivate character with frequent acutenings. Operative intervention is
inevitable anyways, however before operation it is necessary to make out suitable patient's
preparation with stimulation of immune system and detoxicaton.
Torsion of tumor crus
Cystoma cms torsion can happen more often, but sometimes the eras of subserous fibrous
myoma can also happen. Quick motions, pregnancy, labor, stormy bowel peristalsis can cause
torsion. In the result of torsion trophies of tumor tissue disturb, degenerative changes and
necrosis with wall rupture appear in it
Clinic. Complete and incomplete eras torsion may occur. Clinically at eras torsion the
symptoms of "acute abdomen" appear. Muscles of anterior abdominal wall tension is expressed
on the part of process localization. In case of a big tumor its contours are available for palpation
through abdominal wall, and during bimanual examination one can reach a lower tumor pole.
Examination is very painful. In incomplete torsion the clinical picture is poor less and all
phenomena can temporally vanish if blood supply of the tumor will be renewed.
Treatment. Torsion of tumor'eras needs immediate operation. Protraction with
laparotomy gives rise to tumor necrosis, infection, beginning of adhesion's process and accretion
of tumor to adjacent organs, that will create additional complications during the operation. An
operation volume depends on ovarian tumor type: at benign tumor it is removed; in suspicion of
malignization total hysterectomy with omentum resection is indicated.
There is a peculiarity in the operation: clench is laid more proximally from the place of
torsion and the tumor is cut off without twisting its crus. It is forbidden to twist the crus because
the thrombs those are in crus and also substances of necrotic destruction of the tumor can get into
woman's blood.
1. Etiology, pathogenesis and classification of extrauterine pregnancy.
2. Clinical signs of progressing extrauterine pregnancy and the methods of its
diagnostics.
3. Clinical signs of interrupted extrauterine pregnancy and the methods of its
diagnostics.
4. Clinical differences of extrauterine pregnancy interrupted by the rupture of the
uterine tube and tubular abortion.
5. Differentiation diagnostics of extrauterine pregnancy and acute appendicitis.
6. Methods of surgical treatment of extrauterine pregnancy.
7. Indications for concervative treatment of tubular pregnancy.
8. Methods of concervative treatment of tubular pregnancy.
9. Cervical pregnancy. Diagnostics and treatment.
1. A 31- year- old patient is admitted in the gynecological department
complaining of severe blood discharge from the genitals, weakness, and dizziness. She
experienced measles, parotitis flu, frequent quinsy. Menstrual cycle is not regular,
starting from the age of 12. She became sick 15 days ago, when blood discharge
appeared from the genitals after 2 months of delay. The following days intensity of
bleeding increased, weakness and dizziness developed. A general condition is of
moderate severity. Pulse is 90. BP- 80/70, mercury. The tongue is moist and clean. The
patient is of an average fatness, the mammary glands are poorly developed. Heart or lung
pathology is not found. Blood analysis: haemolobin- 50g/l, erythrocytes- 2200000.
Rectal-abdominal examination: smooth and conical cervix, uterine body is in the normal
position, small, mobile, painless. The adnexa are not detected on the both sides. Blood
discharge with clots.
Diagnosis. Plan of treatment. Measures concerning prevention of uterine
bleeding.

References
412.

4 course

FAMILY PLANNING
TOPIC 9. INFERTILE COUPLE. FAMILY PLANNING.

Marriage is considered to be sterile, if during 1 year of regular sexual life without using of
contraceptives, pregnancy does not occur. Infertility happens in 10-12% of all marriages. It is
subdivided into male, female and mixed. About 45% of sterile marriages are connected with
male infertility, 55% of them with female infertility.
II. Aim:
- Causes of female and male infertility.
- Couple's examination in case of infertility in marriage.
- Modern principles and methods of treatment female infertility (hormonal, surgical, new
reproductive technologies).
- Advice on Family Planning: Types, benefits counseling process.
- Overview of contraceptive methods, COC, vaginal ring contraceptive patch, injectable,
IUDs, barrier methods and spermicides.
- Methods of fertility recognition, voluntary surgical sterilization, emergency
contraception. Evaluation of the patient.
- Necessary survey conducted routinely before making a decision to use a particular
contraceptive method.
- Family planning for people living with HIV.
- Collect special gynecological history; assess the results of laboratory research at married
infertility.
- Gynecological infertility research at married
- Evaluate the functional state of diagnostic tests in the ovarian endocrine causes infertility
- Evaluate the results of X-ray female genital mutilation.
- Evaluate the results of ultrasound in infertility status (monitoring of follicle)
- Make a plan survey with infertility.
- Make a plan for inspection before making a decision on the use of hormonal and
intrauterine contraception.
- Technology IUD insertion into the uterus
Infertility
EVALUATION
A traditional approach to the diagnostic assessment of human infertility is to simply follow
the path of sperm up the genital tract to the point of fertilization and subsequent implantation.
This conceptual approach suits our biological understanding but is not representative of an
efficient and practical diagnostic approach. As an alternative, infertility categories can be defined
by diagnostic test groups. In this concept there are three groups of factors: (1) male gamete
factor, (2) female gamete factor, and (3) female genital tract factors. This simplified concept is
compatible with the nature of the available diagnostic tests and is quite easy to explain to patients
as their evaluation is undertaken.
DIAGNOSIS AND TREATMENT
Male Gamete Factor
If the male partner produces no sperm, then azoospermia is the diagnosis and the couple
has sterility on the basis of male factor. Compromises of spermatogenesis that result in decreased
numbers, motility, or fertilizing capability of spermatoza are much harder to define. Many
criteria have been applied to semen analysis results in an attempt to distinguish fertile from
infertile males, but this effort has been frustrated by both the surprising fertility of some men
with poor counts and the great variability in counts that is known to occur even in normal fertile
males. Diagnoses that result from such a systematic evaluation range from normal results on
further seminal testing through a wide range of endocrine disorders, anatomical obstructions of
the male system, and failure of the spermatogenic production constituents per se. The incidence
of ejacula-tory dysfunction or sexual dysfunction in infertility populations is not well
documented, but occasional infertility couples will benefit from psychiatric counseling services
with focus on sexual dysfunction problems.
Female Gamete Factor
The periodic shedding of an ovum is necessary for conception, and women who are
physiologically anovulatory, such as prepubertal children, castrate women, and late
postmenopausal women, are sterile. Infertility owing to an ovulatory problem in reproductive-
age women is more difficult to define because all available measures in the clinical setting are
indirect. In other words, the only absolute proof that ovulation has occurred is detection of a
conception or observation of an egg outside the ovary. All other measures, such as menstrual
rhythm, basal body temperature chart, changes in cervical mucus, systemic symptomatology,
urinary pregnanediol excretion, endometrial biopsy, serum progesterone levels, ultrasound
monitoring of follicle growth and collapse, and oral/vaginal electrical resistance, are all indirect.
Therefore, all such tests of ovulation have some false-positive and some false-negative results.
Consequently the clinical significance of normal but rarely occurring ovulation (oligoovulation)
and abnormal ovarian cycles (ovulatory dysfunction) remains a point of diagnostic contention
among some infertility experts. Relatively subtle abnormalities of ovarian cycles can be
practically grouped together, but there are definable subsets. Although it is not totally clear that
detailed characterization of dysfunctional cycles is essential before initiating rational therapy,
advances in management of ovulatory dysfunction have probably been limited by inadequate
scrutiny and subgrouping of study subjects. Numerous names given to abnormal ovarian cycles
include anovulatory cycles, luteal phase deficiency, luteal phase defect, short luteal phase, poor
progesterone surge, luteinized unruptured follicle syndrome, and poor preovulatory follicular
maturation. Although no broad-based prospective study of human populations will probably ever
permit absolute characterization of the incidence and consequences of these entities, studies in
animals such as rhesus monkeys and sheep strongly suggest that cycle fecundity is profoundly
decreased in such abnormal cycles
Several diagnostic tests are available for assessing ovulatory function The patient's history
of menstrual interval is the defining parameter for distinguishing anovulation from normal or
abnormal but cyclic ovarian function Even if the patient is having relatively regular menses at a
normal interval of 28 ± 2 days, additional tests are indicated to distinguish normal ovulatory
function from abnormal cycles. The traditional basal body temperature (BBT) chart can be
reassuring if measurements are normal, but it is difficult to interpret if it does not show a clear-
cut stepwise shift of temperature at midcycle with an appropriate 12+-day luteal interval. In
general, if a BBT chart looks normal, then the clinician can be somewhat reassured, but
confirmation of ovulatory status with additional testing (e g, serum progesterone, endometrial
biopsy) is usually appropriate If, however, the chart looks extremely abnormal or has a subtler
change, such as a slow midcycle temperature nse or an apparently short luteal interval, then ad
ditional testing of ovulation is absolutely required to distinguish normal ovulatory function from
ovulatory dysfunction.
Historically, urinary pregnanediol excretion was used as a direct measure of progesterone
production during the luteal phase This highly reliable measure of ovulatory function is
somewhat cumbersome, and other modalities have subsequently been adopted.
Quite commonly endometrial biopsy is used to evaluate ovulatory dysfunction, and at the
time of its initial validation this technique was estimated to be approximately 80% accurate
relative to menstrual interval, BBT charts, and pregnanediol excretion. Direct measurement of
serum progesterone levels also provides useful assessment of normality of ovarian cycles. A
single midluteal progesterone level that is greater than 15 ng/ml is better than 80% accurate in
distinguishing normal from abnormal cycles. Values between 10 ng/ml and 15 ng/ml are found
often in both normal and abnormal cycles, whereas values less than 10 ng are rare in normal
cycles, especially if samples are drawn during the morning hours. A powerful and persuasive
assessment of ovarian function is the "cycle profile'. In this approach, detailed analysis of a cycle
is generated by daily samples for a panel of reproductive hormones and by performance of serial
ultrasound scans to monitor follicle growth and subsequent collapse. Obviously, such a detailed
approach to cycle analysis is not a practical screening test, but it does provide the "gold
standard" with which other diagnostic tests can be compared. One such modern test is daily
measurement of salivary and vaginal electrical resistance. Patients can easily take these readings
and document characteristic resistance changes, which have greater than 80% correlation with
more intensive cycle monitoring schemes. Because these resistance changes precede ovulation in
the cycle, such a self-administered test should be useful in timing such activities as coitus and
insemination. Other relatively new self-administered ovulation predictor tests depend on
monoclonal antibodies to human luteinizing hormone (LH) and immunosorbent colorimetric
"dipstick" testing of urine samples. Semiquantitative color changes indicate recent occurrence of
the LH surge, and therefore would be expected to slightly anticipate the ovulatory event.
Although these urine LH tests appear to be somewhat helpful in characterizing cycle events,
correlation of results obtained with kits from different manufacturers can be quite variable and
accuracy estimates can vary widely.
Once anovulation or ovulatory dysfunction is diagnosed, some additional evaluation is
necessary to distinguish certain endocrinopathies that commonly disrupt ovulatory function from
primary ovulatory disorders. Many obvious systemic illnesses or metabolic/endocrine diseases
can interfere with normal cyclicity, but only subtler hyperprolactinemia and hypothyroidism are
commonly diagnosed by the consultant gynecologist during infertility evaluation. Although a
complete discussion of evaluation and management of hyperprolactinemia and thyroid disorders
is beyond the scope of this chapter, specific treatment of these entities often restores normal
ovarian function.
Whether caused by pituitary adenoma or idiopathic excess, hyperprolactinemia commonly
responds well to the drug bromocriptine (Parlodel). This potent dopaminergic-receptor agonist
directly inhibits prolactin secretion from the anterior pituitary and is nearly universally effective
in reducing prolactin secretion, whether or not an adenoma is present. Many patients with
hyperprolactinemia have true amenorrhea, whereas others may simply have subnormal luteal
phase production of progesterone. When hyperprolactinemia is the cause of anovulation or
ovulatory dysfunction, normalization of prolactin secretion with bromocriptine therapy can be
expected to result in normal ovulatory function in most patients.
A related abnormality of hyperprolactinemia is primary hypothyroidism. When
hypothyroidism is clinically apparent there is no diagnostic difficulty. However, occasional
patients present with a normal thyroid panel but an elevated thyroid-stimulating hormone (TSH)
level, implying primary compensated (subclinical) hypothyroidism. The proper treatment of
these patients who have mild elevations of TSH (and prolactin) is thyroid hormone replacement.
The typical response is normalization of both TSH and prolactin levels, and restoration of normal
ovarian cyclicity is, again, common.
There are three diagnostic categories of ovulatory dysfunction that are independent of a
prolactin/ thyroid-mediated mechanism. First, ovarian failure can occur at any age. Elevated
gonadotropins are the usual diagnostic test. Treatment of infertility owing to this cause requires
modern reproductive technologies with donor eggs. Second, patients who have normal prolactin
levels and no gonadotropin elevation but are relatively hypoestrogenic are usually described as
having "hypothalamic amenorrhea'. Failure to bleed with a progestin challenge is the usual
diagnostic hallmark of this group of hypogo-nadotropic hypogonadal patients. Truely specific
therapy for this entity is available in the form pulsatile administration of gonadotropin releasing
hormone (GnRH). This highly specific therapy for augmenting pituitary output of gonadotropins
can be somewhat cumbersome but does seem to provide a more regulated ovarian response than
is obtained with other ovulation induction regimens in this group of patients. With no change in
dosage administration, the patient conceived a singleton gestation in the next cycle after this
study. Many patients with hypothalamic amenorrhea fail to respond to clomiphene but do
respond to human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG)
readily, and have a significant risk of multiple gestation in such treatment cycles. Third, a wide
range of ovulatory disturbances that occur in relatively well estrogenized patients are initially
distinguished by withdrawal bleeding after progestin challenge. In general, the designation for all
of these estrogenized patients is polycystic ovarian disease, although there is a wide range of
presentations from mild luteal dysfunction up to and including complete acyclicity and marked
androgen excess. Many of these patients, especially those with milder disturbances, respond to
clomiphene citrate for ovulation induction. The patient conceived a singleton gestation, and hCG
was first detectable in her serum on the day after the study sampling.
For patients who do not conceive after either specific directed endocrine therapies or a trial
of clomiphene, induction of ovulation with hMG and hCG is usually appropriate. Administration
of hMG typically begins between cycle days 2 and 5. Therapy is monitored with daily estradiol
and ovarian ultrasonic scans from approximately day 6 onward. Once one or more follicles
exceed a diameter threshold (usually 18 mm), hCG may be given for ovulatory release. Estradiol
levels provide a measure of the functional state of all follicles within the ovary; thus a very low
estradiol level with large follicles suggest relatively poor health, whereas a very high estradiol
level would imply a significant risk of hyperstimulation, owing to excessive recruitment of large
numbers of small follicles. Experience with hMG/hCG ovulation induction has shown that a
significant number of failed cycles are due to premature luteinization. That is, the LH surge, or at
least a progressive rise in LH levels, may occur before follicle maturation is completed.
Blockade of LH release with long-acting GnRH agonists that downregulate the pituitary has been
effective in preventing this premature luteinization phenomenon. The hope that such agents
would greatly reduce the risk of ovarian hyperstimulation has been only partially fulfilled.
Treatment of milder forms of ovulatory dysfunction, such as luteal phase deficiency (luteal
phase defect), has often been undertaken by providing luteal phase progesterone
supplementation. This can be done with vaginal suppositories of 25 mg twice a day, and
treatment of such luteal phase abnormalities has typically been monitored by correction of
endometrial biopsies from "out of phase" to "in phase." This treatment seems to have reasonable
efficacy that has generally been attributed to an endometnal action of the progesterone
supplement. Recent studies have shown that m cycles m which the luteal progesterone
production is subnormal, the LH secretory pattern is increased. Furthermore, administration of
progesterone in the follicular phase reduces the LH secretory pulse pattern to that found in
normal luteal phases. These observations certainly suggest that luteal phase progesterone
supplements may actually be normalizing function of the hypothalamic pituitary axis as follicle
recruitment is being initiated for the next cycle, rather than ''fixing" an endometrial problem m
the current treatment cycle.
Female Genital Tract Factors
Lower Genital Tract
Although it is obvious that complete or partial vaginal agenesis precludes conception, these
types of defects are seldom found at the time of infertility evaluation. Virtually all of these
abnormalities will have been previously detected during the assess ment of penpubertal
symptoms such as amenorrhea and hematocolpos. Practically speaking, if coital frequency is at
least two to three times per week and true intromission is occurring, then vaginal infertility
factors do not exist.
Cervical factor infertility is often suggested by poor sperm motility or poor sperm survival
in cervical mucus after intercourse one to ten hours earlie.r Cervical factor infertility as a single
diagnosis seems to be relatively rare in practice, and it is easy to understand that cervical mucus
may lack appropriate biophysical properties in women with hypoestrogenic state.s There is little
doubt that the most common cause of the abnormal postcoital test is poor timing of the test
within the cycle, with "good" cervical mucus occurring during the immediate preovulatory
interval (one to three days before ovulation). The second most common cause of a bad postcoital
test is a male factor such as oligospermia. On the other hand, if the male partner has relative
oligospermia but good postcoital test results can be obtained with the couple, then it is difficult
to attnb ute the couple's infertility solely to lack of sperm m the female upper genital tract.
Other than the biophysical properties of cervical mucus that permit sperm penetration and
survival, factors that might be injurious to sperm have also been identified or proposed. Clearly,
antisperm antibodies can be detected in cervical mucus, and if one or more subsets of antibodies
are directed toward critical surface components of spermatozoa, then an immume basis for
infertility can be supposed. The difficulty is a technical limitation in distinguishing irrelevant
antisperm antibodies from those that actually impede sperm migration or fertilization ability.
Independent of immune-mediated mechanisms, an inflammatory process in the cervix, such as
cervicitis, could be nonspecifically toxic to sperm or could alter the physicochemical properties
of cervical mucus Such a toxic mechanism for infertility can be readily imagined, but there
seems to be little data to support this as a important infertility diagnosis
A common iatrogenic cause of hostile-appearing cervical mucus is use of clomiphene for
ovulation induction. Since clomiphene is an antiestrogen, estrogenic stimulation of cervical
mucus production should be decreased. This virtually universal effect argues for use of
clomiphene relatively early in the cycle (days 3-7), rather than the more traditional later
follicular phase use (days 5-9). There is certainly no pharmacologic justification for giving
supplemental estrogens during clomiphene cycles, since (a) this amounts to giving exogenous
agonist to compete with the administered antagonist and (b) if the early follicular phase
administration of clomiphene has not engendered an adequate late follicular phase estradiol rise,
then the dose was probably inadequate. Because there is a significant conception rate with
clomiphene and because virtually all treated patients have some disturbance of cervical mucus
production, it is difficult to conclude that the cervical mucus perturbation is of profound
significance in clomiphene cycles.
No specific directed therapy for cervical factor infertility exists short of the newer
reproductive technologies that mechanically bypass the cervix. Therefore, a reasonable treatment
strategy for a couple with cervical factor infertility would be an interval of prospective
observation of 6 to 12 cycles with subsequent options, including washed intrauterine
insemination, gamete intrafallopian transfer (GIFT) procedure, or in vitro fertilization with
embryo transfer. Because this same sequence of treatment options applies for idiopathic
infertility, there is a general trend away from postcoital testing. If a specific, less invasive
treatment is devised for the management of cervical factor infertility, then distinguishing
between cervical factor infertility and idiopathic infertility will become clinically important
rather than simply academically interesting
Upper Genital Tract
The assessment of the upper female genital tract, including the uterus, fallopian tubes, and
peritoneal cavity, is most efficiently accomplished by performance of a single combined
procedure of laparoscopy, hysteroscopy, and hydrotubation. This outpatient surgical procedure
permits direct visualization of the endometrial cavity with concurrent inspection of the serosal
surface of the myometrium, thereby enhancing the quality of information that is obtained.
Similarly, dye injection at the time of lapa-roscopy may detect tubal patency and permit direct
inspection of the mobility and morphology of the fallopian tubes. The detection of endometriosis
and pelvic adhesions requires an inspection of the peritoneal cavity, these diagnoses cannot be
reliably made without such a direct inspection.
Hysterosalpmgography provides a useful adjunct in the assessment of the uterine cavity
and fallopian tubes either in the setting in which hysteroscopy is not available or as a
confirmatory study of tubal patency, especially if bilateral proximal tubal occlusion was believed
to be present at laparoscopy and hydrotubation.
A variety of intrauterine abnormalities can be found at hysteroscopy or
hysterosalpmgography, including retained intrauterine device, endometrial polyp, leiomyomata,
intrauterine adhesions, and various developmental abnormalities. On hysterosalpmgography it
may be difficult or impossible to distinguish a uterine septum (septate or subseptate) from a
bicornuate or didelphic uterus. At combined hysteroscopy with laparoscopy specific diagnosis
can be immediately made, and if a septum is present, hysteroscopic resection can be performed
at that time.
Occlusion of one or both fallopian tubes is most commonly detected at the time of dye
injection, whether at laparoscopy or at hysterosalpmgography. Occlusion may be bilaterally
proximal or dis tal, or exist at a combination of those sites. If there is proximal tubal occlusion
for which resection and end-to-end reanastamosis can be performed, then fertility rates can
approach those of sterilization reversal operations. If implantation is required, then the fertility
prospects are poor, with no more than 10% of patients conceiving in the first two years after
surgery. Distal tuboplasty of hydrosalpmges is commonly performed, and subsequent pregnancy
rates vary widely. The biggest problem in estimating subsequent outcome is the inability to
assess the functional integrity of the tubal mucosa It is proba bly fair to advise patients that
fimbnoplasties will yield a 25% pregnancy rate in the first two years after surgery, but clearly
this is very variable from individual to individual, depending on the degree of immeasurable
intraluminal injury.
Although laparoscopy may reveal pertinent observations such as polycystic changes of the
ovaries, the most significant diagnoses to be made are presence and extent of pelvic adhesions
and endometriosis. If pelvic adhesions are minimal but constrain tubal motility, then
laparoscopic lysis of adhesions is a reasonable undertaking. Extensive adhesions would generally
require laparotomy for lysis (with or without tuboplasties), and the results of such surgery are
quite variable. If adhesions are extensive, or if the patient has undergone prior procedures for
lysis but has suffered re-formation, then advancement to in vitro fertilization would probably be
the best strategy.
Endometriosis is commonly found at laparoscopy in infertile couples either as the single
detectable diagnosis or with other factors. In severe endometriosis significant destruction of
ovaries and fallopian tubes and formation of extensive pelvic adhesions are associated with an
exceedingly low cycle fecundity, which is only slightly above zero. All milder forms of
endometriosis (minimal, mild, and moderate) seem to have a cycle fecundity that is one-half to
one-fifth that of normal couples, and is not graded m association with disease severity.This
implies that the mechanism of infertility in milder forms of endometriosis may not be the same
as that in severe disease .The current best evidence is that endometriosis is associated with an
intraperitoneal inflammatory process with elevated concentrations of chemical mediators of
inflammation and an increased number of activated phagocytic cells. Either one or both of these
aspects of an established in flammatory process could explain infertility in terms of decreased
sperm survival and possibly injury of eggs or embryos.
Multifactorial Infertility
There is no reason to suppose that infertility factors may not coexist in any couple, and the
clinician and the couple must allow that the "obvious" factor is not the only problem. Therefore,
it is good practice to undertake the assessment of each couple in a systematic way and then
proceed with less invasive or demanding therapies initially as therapeutic trials. Specifically,
male gamete factor can be evaluated by semen analysis and female gamete factor can be initially
evaluated by a luteal phase progesterone or endometrial biopsy, and a large fraction of diagnoses
will be made. It is then quite reasonable to proceed with a more detailed analysis of the male or
complete the endocrine evaluation of the female with ovulatory dysfunction and to initiate a trial
of therapy before proceeding with invasive assessment such as laparoscopy and
hysterosalpingography. For example, if there appears to be ovulatory dysfunction and a trial of
clomiphene is undertaken, four to eight cycles should be sufficient to determine whether this sole
intervention has been effective. At this point completion of the infertility survey is appropriate;
this primarily means performance of laparoscopy, hysteroscopy, and hydrotubation.
If the patient's history or examination initially suggests a particular diagnosis, such as
female genital tract problems or male gamete factor, then those specific areas should be pursued
early in the assessment. For example, if the patient describes cyclic progressive dysmenorrhea,
then it is appropriate to proceed with laparoscopy for evaluation of both her infertility and pelvic
pain syndrome as a very early step.
The incidence of idiopathic (unexplained) infertility is relatively low. Estimates range from
5% to 20%, but the incidence seems to be inversely correlated with the severity of criteria used.
For example, if regular cyclic menses and a luteal progesterone level of more than 4 ng/ml are
taken as sufficient evidence of normal ovulation, then the rate of diagnosis of ovulatory
dysfunction will be very low, compared with the criteria of a normal "cycle profile" with
demonstrated follicular collapse on serial ultrasounds, LH surge detection, and normal luteal
phase progesterone secretion by daily blood samples for an entire cycle. If a couple has
undergone a complete survey, which would include as a minimal assessment semen analysis,
measurement of serum progesterone levels, laparoscopy, hysteroscopy, and hydrotubation with
or without a postcoital test, then idiopathic infertility can be tentatively diagnosed.
Treatment of multifactorial or idiopathic infertility usually comes down to empirical
therapies that are either conservative or aggressive. The most conservative empirical therapy is
prospective observation. This strategy of allowing conceptive attempts with no medical
intervention for six to twelve months frequently makes practical sense and permits treatment-
independent conceptions to occur. The next level of empirical therapies might include more
precise timing of coital activity (e.g., by BBT charts, LH surge indicators, and salivary/vaginal
electrical resistance indicators), use of a condom for a few cycles followed by discontinuation of
condom use for a few cycles, administration of clomiphene for six to eight cycles or empirical
antibiotic such as tetracycline to the woman or the couple, which might treat undetected genital
tract pathogens.
Additional aggressive empirical therapies include several recently developed technological
options. In vitro fertilization with embryo transfer is certainly effective when fallopian tubes are
absent or occluded, and has also been used for a variety of other diagnoses with apparent
success. When the fallopian tubes are present and relatively normal, GIFT or superovulation with
intrauterine insemination can be used. These alternatives appear to be more effective treatment
modalities for many couples in some of the several diagnostic subgroups. All of these
reproductive options currently require the use of ovulation induction drugs to increase the
number of oocytes available It remains to be seen whether these techniques will actually
increase the overall ultimate conception rate, or whether they simply compact several cycles of
conceptive possibilities down into a single event.
KEY TERMS AND DEFINITIONS

Method to place sperm in the female reproductive tract by
means other than sexual intercourse. If the sperm are from the
Artificial Insemination husband, the technique is called artificial insemination
husband (AIH). If the sperm are from another man, the method
has been called artificial insemination donor (AID). Other
terms are donor insemination and therapeutic donor
insemination (TDI).
Various techniques utilized to increase fecundability by
nonphysiologic methods of enhancing probability of
Assisted Reproductive
fertilization. Categories include in vitro fertilization, gamete
Technology
intrafallopian tube transfer, zygote intrafallopian tube
transfer, and tubal embryo transfer.
Asthenospermia Loss or reduction of the motility of the spermatozoa.
Azoospermia Absence of sperm in the semen.
A weak synthetic estrogenic compound with three benzene
Clomiphene Citrate rings given orally to induce ovulation in anovulatory women
with circulating estradiol levels more than 40 pg/mL.
Inducing development of more than one dominant follicle with
pharmacologic agents, usually clomiphene citrate or
Controlled Ovarian
gonadotropins, also called superovulation or multiple
Hyperstimulation (COH)
follicular recruitment (MFR). COH is usually combined with
intrauterine insemination to treat unexplained infertility.
Probability of conception occurring in a population of couples
Fecundability
in a given period of time, usually 1 month.
Surgical technique of removing adhesions between fimbrial
Fimbrioplasty
fronds of the partially occluded distal end of the oviduct.
Gamete Intrafallopian Placement of human ova and sperm into the distal end of the
Transfer (GIFT). oviduct.
Hamster Egg Penetration
Test of the fertilizing ability of human sperm based on their
Assay (Sperm Penetration
ability to penetrate zona-free hamster ova.
Assay)
Formulation made up of equal amounts of follicle-stimulating
hormone (FSH) and luteinizing hormone (LH) derived from
urine obtained from postmenopausal women. The injectable
agent is used to stimulate follicular development in both
Human Menopausal anovulatory and ovulatory women.
Gonadotropin (HMG)
Several urinary extracts are available including one with
proportionality greater FSH activity. Recombinant (pure) FSH
is often used and recombinant (pure) LH is also available as a
supplement.
Fluoroscopic and radiographic visualization of the interior of
Hysterosalpingogram (HSG) the female upper genital tract after instillation of radiopaque
dye.
Intracytoplasmic Sperm Technique by which a single spermatozoon is injected into the
Injection (ICSI) cytoplasm of an ovum.
Inability of couples of reproductive age to establish a
pregnancy by having sexual intercourse within a certain
Infertility period of time, usually 1 year. Infertility is considered primary
if the woman has never been pregnant and secondary if it
occurs after one or more pregnancies.
Placement of spermatozoa that have been separated from the
Intrauterine Insemination seminal fluid into the endometrial cavity through a small
catheter.
Fertilization of human ova by sperm in a laboratory
In Vitro Fertilization
environment.
Luteal Phase Deficiency Deficient progesterone secretion or action resulting in a delay
(Inadequate Luteal Phase) of normal endometrial development.
Operative technique using magnification and fine, nonreactive
Microsurgery
suture material.
Oligozoospermia Presence of fewer than 20 million sperm per milliliter of
(Oligospermia). semen.
Ovarian enlargement to a diameter of more than 6 cm as a
result of stimulation of multiple follicles. In the mild form there
is abdominal pain, distention, and weight gain. In the
moderate form ovarian enlargement is more than 10 cm in
Ovarian Hyperstimulation
diameter with ascites, nausea, and vomiting. Severe OHSS is
Syndrome (OHSS)
associated with hemoconcentration, oliguria, and elevated
serum creatine. Pleural effusions and ascites can be present;
OHSS becomes critical when hypercoagulability and
hypotension occur. This condition may be fatal.
Examination of the cervical mucus to evaluate the presence of
Postcoital Test
sperm several hours after sexual intercourse.
Pronuclear Stage Tubal
Transfer (PROST) or Zygote In vitro fertilization with transfer of the zygote to the oviducts
Intrafallopian Transfer by transabdominal cannulation.
(ZIFT)
Diverticula of the endosalpinx in the muscularis of the isthmic
Salpingitis Isthmica Nodosa
portion of the oviduct.
Removal of adhesions attached to an oviduct that appears
Salpingolysis
normal on gross inspection.
Surgical creation of a new opening of a completely occluded
Salpingostomy
distal end of the oviduct.
Quantitation of various parameters of a recently ejaculated
Semen Analysis
semen specimen analyzed after liquefaction has occurred.
Spinnbarkeit Property of elasticity (distensibility) of cervical mucus.
Greater-than-normal (50%) incidence of abnormal forms of
Teratozoospermia
sperm in semen analysis.
Treatment-Independent
Infertile women conceiving without use of infertility therapy.
Pregnancy.
Tubal Embryo Transfer
Same as ZIFT, except additional incubation to embryo stage
(TET) or Tubal Embryo Stage
occurs before transfer to the oviducts.
Transfer (TEST)
The diagnosis of an infertile couple when ovulation and tubal
Unexplained Infertility
patency, as well as a normal semen analysis, are all present.
Retrieval of sperm from the testis by biopsy or aspiration from
men with azoospermia due to obstruction of the vas deferens or
epididymis (obstructive azoospermia) or without such
Testicular Sperm Extraction
obstruction (nonobstructive azoospermia). The sperm are
injected into ova retrieved by follicle aspiration by the ICSI
procedure.
The term infertility is generally used to indicate that a couple has a reduced capacity to
conceive as compared with the mean capacity of the general population. In a group of normal
fertile couples, the monthly conception rate, or fecundability, is about 20%. This figure is
important for all couples seeking fertility to know, because it will alleviate unrealistic
expectations of immediate success with various therapies, which can only approach 20% per
cycle (with the exception of in vitro fertilization/embryo transfer [IVF-ET]). For most couples
the correct term should be subfertility, suggesting a decreased capacity for pregnancy but not an
impossible feat.
KEY POINTS
• In 1995 about 10% of all U.S. couples with women in the reproductive age group were
infertile—6.2 million women.
• The incidence of infertility steadily increases in women after age 30.
• Among fertile couples who have coitus in the week before ovulation, there is only
about a 20% (monthly fecundability of 0.2) chance of developing a clinical pregnancy
in each ovulatory cycle.
• In about half of fertile couples attempting to conceive the woman will become
pregnant in 3 months, 75% in 6 months, and 90% at the end of 1 year.
• Infertile couples who conceive do not have higher rates of spontaneous abortion or
perinatal mortality than age-matched control subjects.
• In the United States approximately 10% to 15% of cases of infertility are caused by
anovulation, 30% to 40% by an abnormality of semen production, 30% to 40% by
pelvic disease, and 10% to 15% by abnormalities of sperm transport through the
cervical canal. About 10% to 20% of cases are unexplained.
• The primary diagnostic tests for infertility are documentation of ovulation, semen
analysis, and hysterosalpingogram (HSG).
• The basal body temperature (BBT) increases when circulating levels of progesterone
increase, and a sustained increase of BBT occurs following ovulation.
• A sustained rise in BBT or a serum progesterone level greater than 5 ng/mL is
presumptive evidence of ovulation.
• A midluteal-phase serum progesterone level above 10 ng/mL is an indication of
adequate luteal function.
• A high percentage of fertile men will have at least one abnormal parameter in their
semen analysis.
• In women with a normal HSG, a hysteroscopy is unnecessary because it will not detect
additional abnormality.
• Other diagnostic tests for infertility, including (1) measurement of serum prolactin and
TSH in ovulatory women, (2) a late luteal-phase endometrial biopsy, (3) immunologic
tests to detect sperm antibodies, and (4) bacterial culture of cervical mucus and semen.
• There is no evidence that treatment of an abnormality in the tests just listed
significantly improves pregnancy rates compared with withholding therapy.
• Of all the causes of infertility, treatment of anovulation results in the greatest success.
• When ovulation is induced with clomiphene citrate and no other causes of infertility
are present, conception rates over time are similar to those of a normal fertile
population.
• Discontinuation of therapy is the major reason for the reported difference in ovulation
and conception rates in anovulatory women treated with clomiphene.
• More than 90% of women with oligomenorrhea and 66% with secondary amenorrhea
and E2 levels of 40 pg/mL or higher will have presumptive evidence of ovulation
following clomiphene therapy.
• When conception occurs after clomiphene treatment in anovulatory women, the
incidence of multiple gestation is increased to about 8%, nearly all of them being twin
gestations. The incidences of clinical spontaneous abortion, ectopic gestation,
intrauterine fetal death, and congenital malformation are not significantly increased.
• Formation of ovarian cysts is the major side effect of clomiphene treatment.
• About 5% to 10% of women treated with the individualized, graduated, sequential
regimen of clomiphene citrate fail to ovulate with the highest dosage.
• Treatment of anovulation with gonadotropin effects an ovulatory rate of about 100%.
• The pregnancy rate per cycle with gonadotropins is similar to that following
clomiphene therapy (22%).
• The incidence of spontaneous abortion after HMG therapy is high (25% to 35%), and
clinically detectable ovarian enlargement occurs in about 5% to 10% of treatment
cycles.
• If GnRH is used for ovulation induction it needs to be administered in a pulsatile
manner at intervals of 1 to 2 hours.
• For women with polycystic ovaries who do not ovulate following administration of
clomiphene citrate, partial ovarian destruction by electrocautery or laser through the
laparoscope is effective in inducing ovulation.
• Pregnancy rates for oligospermia following intrauterine insemination are in the 25% to
35% range.
• Semen donors need to be carefully screened to be certain that they are in good health,
do not have a potentially inherited disorder, and will not transmit an infectious agent in
the semen.
• Because antibodies to HIV may not develop for several months after infection, it is
recommended that all donor insemination be performed with frozen sperm that has
been stored for at least 6 months at which time negative antibodies to HIV should be
observed in the donor before the sperm is used for insemination.
• The prognosis for fertility after tubal reconstruction depends on the amount of damage
to the oviduct as well as the location of the obstruction.
• If both proximal and distal obstructions of the oviduct exist, intrauterine pregnancy is
uncommon, and operative reconstruction should not be performed, IVF is the best
therapy.
• Women with pelvic tuberculosis should be considered sterile, and no tubal
reconstructive procedures should be attempted. IVF may be attempted if the
endometrial cavity is not infected.
• Overall conception rates following salpingostomy are in the 30% range, with a high
percentage (about one fourth) being tubal pregnancies.
• The pregnancy rate after salpingolysis and fimbrioplasty for partial distal obstruction
is about 65%.
• Unlike the results of distal tubal reconstruction, the use of microsurgery has improved
intrauterine pregnancy rates for proximal tubal disease.
• Proximal tubal obstruction is now usually treated by cannulation of the oviducts with
catheters or balloons placed under hysteroscopic visualization.
• The benefit of second-look laparoscopy after tubal surgery has not been established.
• No medical therapy for endometriosis has proved to increase pregnancy rates
compared with no treatment.
• Pregnancy rates for women with mild endometriosis can be increased with the use of
controlled ovarian hyperstimulation and intrauterine insemination but not with
danazol.
• About 65% of women with mild endometriosis and no other cause of infertility
conceive without treatment. With moderate or severe disease, pregnancy rates with
expectant management are 25% and 0%, respectively.
• Conception rates for women treated surgically have been reported to be in the 50% to
60% range for those with moderate endometriosis and 30% to 40% for those with
severe endometriosis.
• About half of infertile women with myomas conceive after myomectomy.
• Luteal-phase deficiency, as currently diagnosed histologically, is probably a normal
biologic variant and not a true cause of infertility.
• No data conclusively demonstrate that the finding of antisperm antibodies in either
member of the couple is a cause of infertility.
• In women with unexplained infertility the use of controlled ovarian hyperstimulation
(COH) and intrauterine insemination (IUI) yields monthly fecundity rates of 10% to
15%. Therefore COH and IUI should be the initial treatment for women who ovulate,
have patent oviducts, and whose male partner has at least 5 million motile sperm in the
ejaculate.
• For IVF with and without ICSI the delivery rate per cycle in which ova are retrieved is
as high as 40% depending on the age of the woman.
• The rate of pregnancy following IVF is directly related to the number of embryos
placed in the uterine cavity.
• The pregnancy rate per cycle of IVF remains relatively constant for about six cycles
after which it declines. After six cycles the cumulative pregnancy rate is about 60%.
• There is a high spontaneous abortion rate (about 30%) for pregnancies after IVF.
• If an infertile couple fails to conceive after 2 years of therapy, they should be informed
the chances for conception are remote.
• The optimal treatment for all causes of sperm abnormalities is ICSI. With this
technique, pregnancy rates per cycle are similar to that of IVF performed for other
causes of infertility.
Family Planning : Contraception, Sterilization, and Pregnancy Termination
KEY TERMS AND DEFINITIONS

Contraception. The prevention of pregnancy.
Pregnancy rates with various types of contraceptives at different intervals,
Contraceptive
usually years. This rate is frequently expressed as number of pregnancies
Failure Rate.
per 100 women at 1 year or per 100 woman-years.
An adhesive matrix 20 cm2 patch containing ethinyl estradiol and
Contraceptive
norelgestromin that is placed transdermally by the user. The steroids are
Patch.
delivered into the circulation for 1 week.
A flexible soft transparent ring-shaped device containing etonogestrel and
Contraceptive
ethinyl estradiol that is placed in the vagina. The steroids are delivered
Ring.
into the circulation at a constant rate for 3 weeks.
Emergency Administration of steroids or insertion of a copper IUD within 3 to 7 days
Contraception. after a single episode of unprotected, midcycle sexual intercourse.
Intentional medical or surgical termination of pregnancy before 20 weeks'
gestation. Also called elective pregnancy termination if performed for the
Induced Abortion.
woman's desires or therapeutic abortion if performed for reasons of
maintaining the mother's health.
A small device, usually made of plastic with or without copper or a
Intrauterine progestin, placed into the endometrial cavity to provide an effective method
Device (IUD). of contraception. Also called intrauterine contraceptives (IUC) or
intrauterine systems (IUS).
Incidence of adverse events, such as expulsion, removal for medical
IUD Event Rates.
reasons, and pregnancy, at various times after insertion of an IUD.
An ethylene vinyl acetate rod containing etonogestrel that is placed in the
Implant. subcutaneous tissue of the upper arm and provides excellent contraceptive
effectiveness for 3 years.
An actuarial technique for determining rates of occurrence of events, such
Life Table
as pregnancy and discontinuation, at various intervals after starting any
Method.
type of contraceptive.
Perfect Use The rate of effectiveness when the contraceptive method is always used
Effectiveness. correctly. Previously called method use.
Natural Family Periodic abstinence from intercourse during the periovulatory time of the
Planning. cycle. Also known as rhythm.
A device that is inserted transcervically through a hysteroscope into the
Microinsert.
proximal portion of the oviduct to provide permanent tubal occlusion.
Oral Formulations of various synthetic progestins usually combined with a
Contraceptive synthetic estrogen that are ingested orally to prevent conception. When the
Steroids (OCs). progestin is combined with an estrogen the formulation is called a
combination oral contraceptive (COC). Oral progestin tablets without
estrogen are called minipills.
A nonactuarial method used for determining the pregnancy (failure) rate of
any contraceptive technique:
Pearl Index.
A class of sex steroids having progestational activity. The terms

Progestin.
progestogen and gestagen are synonymous.
A local contraceptive containing the surfactant nonoxynol 9, which is toxic
Spermicide.
to sperm.
Prevention of pregnancy by vasectomy or tubal interruption or blockage.
Sterilization.
This method of contraception should be considered permanent.
Typical Use Overall effectiveness rate in actual use for a specific contraceptive method.
Effectiveness. Previously called use effectiveness.
Reversible contraception is defined as the temporary prevention of fertility and includes

all the currently available contraceptive methods except sterilization. Sterilization should be
considered a permanent prevention of fertility even though both vasectomy and tubal interruption
can usually be reversed by a meticulous surgical procedure. The reversible methods are also
called active methods, and sterilization is also called a terminal method. A perfect method of
contraception for all individuals is not currently available and probably will never be developed.
Each of the various methods of contraception currently available has certain advantages and
disadvantages. Therefore, when giving advice about contraception, the clinician should explain
to the couple the advantages and disadvantages of each method, so they will be fully informed
and can rationally choose the method most suitable for them. Because no reversible
contraceptive method other than the condom has yet been developed for use by the male, the
contraceptive provider generally counsels the female partner and should inform her if there are
medical reasons that contraindicate the use of certain methods and offer her alternatives.
KEY POINTS
• In 2002, of the 62 million women in the United States ages 15 to 44 years,
approximately one third were not at risk for pregnancy, and 62%, 38 million, were
using a method of contraception. About 7% of women of reproductive age were
sexually active and not using any contraceptive.
• In 2001, there were about 6.4 million pregnancies in the United States. There were 4
million births and about 1.3 million elective abortions. Half of all pregnancies were
unintended. About 20% of all pregnancies were electively terminated.
• Of women ages 15 to 44 in the United States in 2002, male and female sterilization
were used by 22%, oral contraceptives by 19%, male condom by 11%, the progestin
injection by 3%, and the IUD by 1.3%.
• Typical and perfect use failure rates in the first year of use range between 5% and 27%
for coitus-related methods beween 0.3% and 8% for oral contraceptives (OCs) and
0.3% to 3% for the injection. The IUD and implants have typical use failure rates less
than 1%.
• Contraceptive failure rates are increased in inverse relation to the user's age, level of
education, and socioeconomic class.
• Pregnancy results from failure of spermicide use are not associated with an increased
risk of fetal malformations.
• The active ingredient in spermicides is a surfactant, usually nonoxynol 9, which
immobilizes or kills sperm on contact.
• Barrier techniques reduce the rate of transmission of sexually transmitted diseases,
both bacterial and viral.
• The most effective type of periodic abstinence is the symptothermal method.
• OC formulations in the United States consist of varying dosages of one of the
following progestins: estranes: norethindrone, norethindrone acetate, ethynodiol
diacetate, or gonanes: norgestrel (or its active isomer, levonorgestrel), desogestrel,
norgestimate, or a spironolactone derivative, drosperinone and either of two estrogens,
ethinyl estradiol or ethinyl estradiol-3-methyl ether, also called mestranol.
• A given weight of norgestrel or the other gonanes has 5 to 10 times more
progestational activity than the equivalent weight of norethindrone, whereas
norethindrone acetate and ethynodiol diacetate are similar in potency to norethindrone.
• Metabolic effects of the estrogen component of OCs include an increase in serum
globulins that have a thrombophilic effect and altering of the lipid profile to increase
triglycerides and HDL cholesterol and lower LDL cholesterol.
• Metabolic effects of the progestin component of OCs include peripheral insulin
resistance and lowering HDL cholesterol and raising LDL cholesterol.
• Ethinyl estradiol is approximately 1.7 times as potent as an equivalent weight of
mestranol.
• No significantly increased risk of breast cancer occurs among current or former users
of OC or in various high-risk subgroups of OC users.
• OC users have an increased risk of developing invasive cervical cancer, particularly
adenocarcinoma, compared with users of no contraception, but a causal relation has
not been established.
• The rate of return of fertility after stopping OCs is delayed, but eventually the
percentage of women who conceive after stopping all methods of contraception,
including OCs, is the same.
• Babies born to women who discontinue OCs or who conceive while ingesting OCs
have no greater incidence of any type of birth defect.
• All OC formulations with less than 50 μg of estrogen increase the risk of venous
thrombosis and embolism three- to fourfold.
• A significantly increased risk of developing MI occurs only in current OC users older
than age 35 who smoke.
• Users of low-dose OCs do not have a significantly increased risk of developing
ischemic or hemorrhagic stroke if they do not smoke or have hypertension.
• The cause of MI in older OC users who smoke is arterial thrombosis.
• Adverse effects produced by the estrogenic component of OCs include nausea, breast
tenderness, fluid retention, temporary increase in blood pressure, thrombosis, changes
in mood, and chloasma. Progestins produce certain androgenic adverse effects,
including weight gain, nervousness, depression, tiredness, and acne, as well as failure
of withdrawal bleeding or amenorrhea.
• In an ovulatory cycle the mean blood loss during menstruation is approximately 35
mL, compared with 20 mL for women ingesting OCs.
• OC users are about half as likely to develop iron deficiency anemia as are control
subjects.
• OC users are significantly less likely to develop menor-rhagia, irregular menstruation,
or intermenstrual bleeding than nonusers.
• The risk of developing endometrial cancer, as well as ovarian cancer, in OC users and
former users is only half that in control subjects. OC users also have a 50% reduction
in the incidence of benign breast disease.
• OC users have approximately 50% less dysmenorrhea and about 40% less
premenstrual disorders than do control subjects.
• Functional ovarian cysts occur less frequently in OC users than in nonusers if they use
monophasic, but not multiphasic, formulations.
• Prior use of OCs does not affect mortality rates in women.
• OCs reduce the clinical development of salpingitis (PID) in women infected with
gonorrhea or Chlamydia by 50%, and the overall incidence of PID in OC users is
reduced by 50%.
• OCs reduce the risk of ectopic pregnancy by more than 90% in women currently using
them.
• There are three types of injectable contraception: depomedroxyprogesterone acetate
(DMPA), norethindrone enanthate, and several progestin–estrogen combinations. All
are very effective.
• Women using injectable DMPA (150 mg every 3 months) intramuscularly or 104 mg
subcutaneously have a first-year pregnancy rate of 0.1%.
• Injectable DMPA is associated with loss of bone density that recovers after DMPA is
stopped.
• Women treated with injectable progestins for contraception have complete disruption
of the normal menstrual cycle and an irregular bleeding pattern that is usually followed
by amenorrhea.
• The most effective method of emergency contraception is ingestion of two tablets of
750 μg of levonorgestrel taken 12 hours apart with a failure rate about 1%.
• The contraceptive patch is applied to the skin for seven days. Effectiveness and
adverse effects are similar to OCs.
• The contraceptive vaginal ring is placed in the vagina for 3 weeks. Effectiveness and
adverse effects are similar to OCs.
• The cumulative incidence of accidental pregnancy with the copper T 380A IUD is
1.6% after 7 years of use and 1.7% after 12 years of use. This IUD is approved for 10
years' use.
• The incidence of adverse events with IUDs steadily decreases with increasing age of
the woman.
• The main mechanism of contraceptive action of the copper IUD is production of a
local sterile inflammatory reaction of leukocytes, which destroys sperm and prevents
fertilization.
• Resumption of fertility after IUD removal is not delayed and occurs at the same rate as
resumption after discontinuation of use of mechanical contraceptive methods.
• A copper or progesterone-releasing IUD can be removed and a new one reinserted
immediately afterward. The IUD can be safely inserted on any day of the cycle.
• In the first year of use, the copper T 380 IUD has approximately a 0.5% pregnancy
rate, a 10% expulsion rate, and a 15% rate of removal for medical reasons, and the
incidence of each of these events diminishes steadily in subsequent years.
• In women wearing a copper T IUD, 50 to 60 mL of blood is lost per cycle; with the
levonorgestrel-releasing IUS, the amount of blood loss is about 5 mL per cycle.
• Mefenamic acid, 500 mg twice daily during menses, significantly reduces menstrual
blood loss in IUD users.
• The fundal perforation rate with the copper T 380 IUD is about 1 per 3000 insertions.
• The incidence of congenital anomalies is not increased in infants born with any type of
IUD in utero.
• If a woman conceives with an IUD in place and the IUD is not removed, the incidence
of spontaneous abortion is about 55%, approximately three times greater than would
occur without an IUD. If, after conception, the IUD is removed, the incidence of
spontaneous abortion is reduced to about 20%.
• If a woman conceives with a copper IUD in place, her chances of having an ectopic
pregnancy is about 5%, approximately 10 times greater than occurs in conceptions
without an IUD.
• Women using a copper T 380 IUD have approximately a 90% lower overall risk of
having an ectopic pregnancy than women using no method of contraception.
• The rate of prematurity among live births occurring with an IUD in utero is increased
about two to four times.
• The overall risk of PID in users of IUDs with a monofilament tail string is increased
only during the first 3 weeks after insertion.
• Pregnancy rates after reanastomosis of the vas range from 45% to 60%, whereas those
after oviduct reanastomosis range from 50% to 80%.
• About 1% of sterilized women request reversal. In the United States approximately
7000 women request reversal each year.
• Usually about 15 to 20 ejaculations are required after vasectomy before a man is
sterile.
• After vasectomy, two aspermic ejaculates are required before the male is considered
sterile.
• After sterilization by tubal interruption, the 1-year failure rate is 0.55 per 100 women,
the 5-year failure rate is 1.31 per 100 women, and the 10-year failure rate is 1.85 per
100 women. About one third of the pregnancies are ectopic.
• Complication rates are three to four times higher for second-trimester abortions than
for first-trimester abortions.
• The most effective medical means to terminate pregnancies less than 8 weeks'
gestation is the combination of mifepristone followed by misoprostol, with a failure
rate less than 5%.
• A single subdermally placed implant containing etonogestrel provides excellent
contraceptive effectiveness for 3 years.
• A microinsert placed into the oviducts transcervically provides very effective
permanent pregnancy prevention.
Theoretical questions to the class:

1. What dоes the notion «infertile marriage» comprise?
2. What are the kinds of infertile marriage?
3. Qualitative and quantative indices of fertile sperm.
4. Causes of female infertility.
5. Diagnostic methods of tubular infertility.
6. Diagnostic methods of endoscopic infertility.
7. Algorithm of examination of a family couple with immunologic infertility.
8. Indications and contraindications for surgical treatment of tubular infertility.
9. Indications for extracorporal fertilization.
10. Therapeutic principles of endocrine infertility.
5.3. Practical tasks performed during the class:
1. Methods of functional diagnostics, their estimation.
2. Estimation of the curve of a basal temperature, cytological smears, estimation of the hormone
level in the blood.
3. Microscopic picture of the endometrium in various phases of the menstrual cycle.
4. Methods of examination of gynecological patients.
B. Tests for self-assessment
1. Frequency of infertile marriages constitutes:
A. 5-10%
B. 15-20%
C. 5-20%
D. 35-40%
E. more 40%.
2. Can colpitis be a cause of infertility?
A. Yes.
B. No.
3. Can the change of cervical pH be the only cause of infertility?
A. No.
B. Yes.
References
412.

LIST OF QUESTIONS FOR PREPARING STUDENTS OF 4TH COURSE
CYCLE “DISEASES OF FEMALE REPRODUCTIVE SYSTEM.
FAMILY PLANNING”
1. General and special methods of examination gynecological patients.

2. Bimanual, vaginal, examination through the rectum. Examination using
vaginal mirror.
3. Methods of functional diagnostics of the condition of the ovaries.
4. Etiology, pathogenesis, classification of inflammatory diseases of the female
genital organs. Peculiarities in different age periods.
5. Regulation of the menstrual cycle.
6. Secondary amenorrhea. Stein-Leventhal syndrome, pathogenesis, clinical
manifestations, diagnosis and treatment.
7. Secondary amenorrhea. Sheehan's Syndrome, Symondsa, pathogenesis,
clinical manifestations, diagnosis and treatment.
8.
9. Genital candidosis. Symptoms, diagnosis and treatment.
10. Genital herpes. Symptoms, diagnosis and treatment.
11. Bacterial vaginosis. Etiology, clinical manifestations, diagnosis and
treatment.
12.Tuberculosis of female genitals.
13.Classification of disorders of menstrual function, primary amenorrhea.
14.The uterine forms of amenorrhea. Asherman syndrome, symptoms,
diagnosis, treatment.
15.Adenomyosis. Etiology, pathogenesis, clinical manifestations, diagnosis and
treatment.
16. Juvenile uterine bleeding. Etiology, clinical manifestations, diagnosis and
treatment.
17. Menopausal bleeding. Etiology, clinical manifestations, diagnosis and
treatment.
18. Dysmenorrhea. Etiology, classification, clinical features and treatment.
19. Vulvitis. Symptoms, diagnosis, treatment.
20. Causes of female and male infertility. Forms of female infertility.
21. Examination of couple infertility in marriage.
22. Modern principles and methods for treating female infertility.
23. Contraceptives. Classification, mechanism of action and effectiveness of
modern contraceptives.
24. Endometriosis. Etiology, pathogenesis, classification, clinical picture,
diagnosis and modern treatment methods.
25.Endocervicitis. Symptoms, diagnosis, treatment.
26.Acute endometritis. Etiology, pathogenesis, clinical manifestations,
27.Chronic endometritis. Etiology, pathogenesis, clinical manifestations,
28.The concept of the cyst and ovarian cysts. Classification of ovarian tumors.
Symptoms, diagnosis and treatment.
29.Acute salpingingitis. Etiology, pathogenesis, clinical manifestations,
30.Methods of conservative and surgical treatment of uterine fibroids.
Indications for surgical treatment.
31.Cancer of the vulva. Classification, clinical manifestations, diagnosis and
treatment.
32.Cancer of the vagina. Classification, clinical manifestations, diagnosis and
treatment.
33.Cervical Cancer. Classification, clinical manifestations, diagnosis and
treatment.
34.Uterine cancer. Classification, clinical manifestations, diagnosis and
treatment.
35.Sarcoma of the uterus. Classification, clinical manifestations, diagnosis and
treatment.
36.Ovarian cancer. Classification, clinical manifestations, diagnosis and
treatment.
37.Cancer of the uterine tube. Classification, clinical manifestations, diagnosis
and treatment.
38.Trophoblastic disease. Diagnosis and treatment.
39.Ovarian apoplexy. Differential diagnosis of surgical pathology.
40. Torsion stem tumor. Differential diagnosis of surgical pathology.
41. Rupture of the capsule of the tumor of the ovary.
42. Purulent tumor. Differential diagnosis of surgical pathology.
43. Traumatic injuries of the genital organs. Differential diagnosis of surgical
pathology.
44. Chronic salpingitis. Etiology, pathogenesis, clinical manifestations,
45. Ovarian masses. Etiology, pathogenesis, clinical manifestations, diagnosis,
treatment.
46. Parametritis. Etiology, pathogenesis, clinical manifestations, diagnosis,
treatment.
47. Pelvioperitonitis. Etiology, pathogenesis, clinical manifestations, diagnosis,
treatment.
48.Gonorrhea. Classification, clinical manifestations, diagnosis, treatment,
provocation methods.
49.Chlamydia. Symptoms, diagnosis, treatment.
50.Ureaplasmosis. Symptoms, diagnosis, treatment.
51.Malformations of female genital mutilation. Atresia. Symptoms, diagnosis,
treatment.
52.Pelvic organ prolapse. Symptoms, diagnosis, treatment.
53.Ovarian cysts. Etiology, pathogenesis, clinical manifestations, diagnosis and
treatment.
54.Cystomas. Etiology, pathogenesis, clinical manifestations, diagnosis and
treatment.
55.Leiomyomas. Classification, etiology, pathogenesis, clinical features,
diagnostic methods.
56. Craurosis of vulva. Etiology, pathogenesis, clinical manifestations,
57.Cervical dysplasia. Classification and diagnosis, doctor's tactics.
58.Polyps and hyperplasia of the cervical canal. The clinic, diagnostics, medical
tactic.
59.Polyps and endometrial hyperplasia. The clinic, diagnostics, medical tactic.
60.Cervical erosion. Etiology, pathogenesis, types of erosion.
61.True and false cervical erosion. Symptoms, diagnosis, treatment.
62.Ectopic pregnancy. Etiology, pathogenesis, classification.
63. Progressive ectopic pregnancy. Etiology, clinical manifestations, diagnosis
and treatment.
64. Interrupted by type of ectopic pregnancy rupture. Symptoms, diagnosis,
treatment.
65. Interrupted ectopic pregnancy by type of tubal abortion. Symptoms,
66.Differential diagnosis of ectopic pregnancy with acute abdominal pathology.
67. Perforation of the uterus. Tactics doctor.
68. Gynecologic aspects of breast cancer. Breast.
69. Ages of women. Hormones women.
70. Instrumental methods gynecological examination of women.
71. Endoscopic methods gynecological examination of women.
72. Regulation of the menstrual cycle. Ovarian cycle.
73. Regulation of the menstrual cycle. Uterine cycle.
74. Gonadal dysgenesis, adreno-genital syndrome. Symptoms, diagnosis and
treatment.
75.Leiomyomas of the uterus and pregnancy.
76. Conservative treatment leyomiom shows to conservative treatment.
77. Operative treatment leyomiom, indications for surgical treatment.
78. The concept of anatomical and surgical foot cysts. Cysts and ovarian
cystoma, classification, etiology and pathogenesis.
79. Dermoid cysts. Etiology, clinical manifestations, diagnosis and treatment.
80. Ovarian tumors. Symptoms, diagnosis and treatment.
81. Epithelial cyst. Symptoms, diagnosis and treatment.
82. Epithelial cystomas. Symptoms, diagnosis and treatment.
83.Endometriomas. Etiology, pathogenesis, clinical manifestations, diagnosis
PRACTICAL SCILLS
DISEASES OF FEMALE REPRODUCTIVE SYSTEM.
FAMILY PLANNING.
1. Gynaecological research (mirror, bimanual, rectal, rektovagial).
2. To collect the special gynaecological anamnesis, estimate the results of laboratory research (global and
biochemical analyses of blood, urine, coagulation the system of blood and other).
3. Taking the material from vagina, urethra and cervikal channel.
4. To estimate the results of Colpotcitological research.
5. To estimate the results of Colposkopic research.
6. To estimate the tests of diagnostics of the functional state of ovaries.
7. To estimate the results of citologichal, histological, bacteriological researches.
8. To estimate the results of roentgenological researches of womanish privy parts.
9. To estimate the results of USD.
10. To work out a plan of inspection of sick at different kinds gynaecological pathology.

Method Recommendations 4

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STATE ESTABLISHMENT

"DNІPROPETROVSK MEDICAL ACADEMY OF THE MINISTRY OF HEALTH OF

DISCIPLINE “OBSTETRICS AND GYNECOLOGY”

DISEASES OF FEMALE REPRODUCTIVE SYSTEM

GUIDELINES WERE APPROVED AT A MEETING OF THE DEPARTMENT OF

GUIDELINES WERE REVISED AT THE MEETING OF THE DEPARTMENT OF

GUIDELINES WERE REVISED AT THE MEETING OF THE DEPARTMENT OF

DISEASES OF FEMALE REPRODUCTIVE SYSTEM

Topic 1. PHYSIOLOGY OF THE FEMALE GENITALS ORGANS. METHODS OF

Amount of hours: 3 hours in practical classes

I. Scientific and methodical grounds of the theme.

III. Recommendations to the student

Examination of gynecological patient consists of history taking, objective (general and

Fig. 20. Single-blade Sims Fig. 21. Bivalve Cuskoe's

Fig. 22. Examination of uterine cervix by Cuskoe's speculum:

After cervical examination speculum is gradually withdrawn, inspecting vaginal walls.

Fig. 26. Pap smear:

• IV type — suspicion on malignisation, intraepithelial cancer should be possible

Test name Points quantity

• maturity index is a correlation of superficial, intermediate,

II. Multiple Choice.

Students must know:

Students should be able to make:

2.Plan the treatment of the patients with inflammatory diseases .

3.Plan the delivery of the patients with inflammatory diseases .

4.Plan the postpartum care of the patients with inflammatory diseases

DISEASES OF FEMALE REPRODUCTIVE SYSTEM

Topic 2. Neuroendocrine regulation. Dysfunction of the reproductive system.

I. Scientific and methodical grounds of the theme

PHYSIOLOGY OF THE FEMALE GENITAL ORGANS

Regulation of menstrual cycle

Fig. 11. Regulation of menstrual cycle:

Progesterone ng/ml ~~■"■■ LH mU/ml

Hypothalamic ventromedial, arcuate and dorsomedial nuclei produce such hormones as

Fig. 15. Phase of endometrial proliferation Fig. 16. Phase of

stimulates the production of LTH-in pi-

Fig. 18. Biopsy of endometrium on

Cyclic changes in uterine tubes

It is recommended to carry out the following problems for self-preparation and

DISEASES OF FEMALE REPRODUCTIVE SYSTEM

TOPIC 3. NEUROENDOCRINE SYNDROMES IN GYNECOLOGY.

Amount of hours: 3 hours in practical classes

6. Etiology and pathogenesis of neuroendocrine syndromes.

7. Clinical signs and diagnostic methods of neuroendocrine syndromes.

8. Modern principles of treatment of neuroendocrine syndromes.

1. To know the main etiological and pathgenetic reasons of disorders of the

.4. Basic knowledge.

Name of the course Received skills

Methodological gydelance was made by assistant professor of obstetrics and gynecology

DISEASES OF FEMALE REPRODUCTIVE SYSTEM

TOPIC 4. BENIGN TUMORS OF THE FEMALE GENITAL ORGANS.

Amount of hours: 3 hours in practical classes

I. Scientific and methodical grounds of the theme

Methodological gydelance was made by assistant professor of obstetrics and gynecology

DISEASES OF FEMALE REPRODUCTIVE SYSTEM

TOPIC 5. BACKGROUND AND PRECANCEROUS DISEASES OF FEMALE

III. Recommendations to the student

Methodological gydelance was made by assistant professor of obstetrics and gynecology

DISCIPLINE “OBSTETRICS AND GYNECOLOGY”

DISEASES OF FEMALE REPRODUCTIVE SYSTEM

Amount of hours: 3 hours in practical classes

I. Scientific and methodical grounds of the theme

Key words and phrases: inflammatory diseases.