Practical Gynecology

Clinical Lecture Notes

CLN
Mzhda Sahib Ja'far

Typed by: Designed by:

1st Edition
Table of Contents
What are the conditions that gynecology deals with? .............................................................1
History Taking in Gynecology ........................................................................................................1
Demographic Data...........................................................................................................................1
Chief complaint .................................................................................................................................1
History of present illness .................................................................................................................1
Gynecological History .....................................................................................................................1
1. Menstrual History ...................................................................................................................1
2. Contraception .........................................................................................................................2
3. History of Infertility ................................................................................................................2
4. Vaginal discharge..................................................................................................................2
5. Incontinence .............................................................................................................................3
6. History of pap smear ‫ فحصى شووشە‬............................................................................3
7. Any prolapse ..........................................................................................................................3
8. Sexual History ........................................................................................................................3
Past obstetrical history ....................................................................................................................3
Social History ....................................................................................................................................3
Family History ...................................................................................................................................3
Drug, Allergy & Blood Transfusion ................................................................................................3
Medical history .................................................................................................................................3
Surgical history .................................................................................................................................3
Examination.........................................................................................................................................3
Inspection ...........................................................................................................................................3
Internal Inspection .........................................................................................................................3
Palpation............................................................................................................................................4
Normal Menstrual Cycle ...................................................................................................................4
Physiology..........................................................................................................................................4
Fertility & Infertility ..........................................................................................................................4
For Fertilization We Need ..........................................................................................................4
Types of infertility.........................................................................................................................4
How we can know that a ♀ is fertile from history? ................................................................5
How to investigate a woman when she is a suspected case of infertility? .........................5
Disorders of the Menstrual Cycle ...................................................................................................6
 Heavy or Irregular Cycle ................................................................................................................6
Causes .............................................................................................................................................6
Amenorrhea .......................................................................................................................................6
Primary Amenorrhea ....................................................................................................................6
Secondary Amenorrhea ...............................................................................................................7
Post-Menopausal Bleeding .............................................................................................................7
Causes .............................................................................................................................................7
How to Approach? ........................................................................................................................8
Notes ...............................................................................................................................................8
Heavy Menstrual Bleeding (Menorrhagia) ..................................................................................8
Causes .............................................................................................................................................8
How to Approach..........................................................................................................................8
Management..................................................................................................................................8
Fertility Control (Contraception) .....................................................................................................9
Types ..................................................................................................................................................9
1. Microgynon .................................................................................................................................9
2. HD ................................................................................................................................................9
3. Yasmin .........................................................................................................................................9
4. LD .............................................................................................................................................. 10
Indications.................................................................................................................................... 10
5. Diane 35 .................................................................................................................................. 10
6. Depo – provera ...................................................................................................................... 10
7. (Androgen Effect) (Male Side) ............................................................................................. 10
8. Provera..................................................................................................................................... 10
9. Lenestrnol ................................................................................................................................. 10
10. I-pill........................................................................................................................................ 11
11. Condom ................................................................................................................................. 11
12. HRT......................................................................................................................................... 11
13. IUCD ...................................................................................................................................... 11
Contraindication ......................................................................................................................... 11
Complications.............................................................................................................................. 11
Notes ............................................................................................................................................ 11
Failure Rate................................................................................................................................. 11
 Mechanism ................................................................................................................................... 11
Notes on Intrauterine Device (IUD) (Copper T) ..................................................................... 11
14. Merena (Hormonal IUD). .................................................................................................... 12
Its Action ...................................................................................................................................... 12
Indications.................................................................................................................................... 12
Note on contraceptive pills generally ....................................................................................... 12
Abortion ............................................................................................................................................. 12
Types ............................................................................................................................................... 12
1. Threatened Abortion .......................................................................................................... 12
2. Incomplete Abortion............................................................................................................ 12
3. Induced Abortion ................................................................................................................. 13
4. Missed abortion (Miscarriage).......................................................................................... 13
5. Complete Abortion.............................................................................................................. 13
Types of Abortion & Their Characteristics ................................................................................ 13
Causes ............................................................................................................................................. 14
Management .................................................................................................................................. 14
Missed – Miscarriage ................................................................................................................ 14
Threatened abortion ................................................................................................................. 15
Incomplete miscarriage ............................................................................................................. 15
Legal ............................................................................................................................................ 15
Illegal ........................................................................................................................................... 15
Illegal subsequent ...................................................................................................................... 15
Septic miscarriage ..................................................................................................................... 15
Religious Abortion ...................................................................................................................... 15
Management of a Woman With Miscarriage...................................................................... 15
Misoprostol ..................................................................................................................................... 16
(< 𝟏𝟐 𝒘𝒆𝒆𝒌𝒔) ........................................................................................................................... 16
(> 𝟏𝟐 𝒘𝒆𝒆𝒌𝒔) ........................................................................................................................... 16
Side effects of misoprostol ....................................................................................................... 16
Requirements for Curettage ........................................................................................................ 16
What Are The Steps For Doing Curettage? ............................................................................. 17
D & C (Dilatation & Curettage) ..................................................................................................... 17
Ergometrin....................................................................................................................................... 18
 Contraindications of Ergometrin .............................................................................................. 18
What are the complications of curettage? ............................................................................... 18
Immediate.................................................................................................................................... 18
Late............................................................................................................................................... 18
Some Notes .................................................................................................................................... 18
Trophoblastic Diseases .................................................................................................................. 19
Types: .............................................................................................................................................. 19
Presentation:- ................................................................................................................................. 19
Diagnosis ......................................................................................................................................... 19
Causes ............................................................................................................................................. 19
Treatment ........................................................................................................................................ 19
Follow Up ........................................................................................................................................ 20
8 days course. ............................................................................................................................ 20
Notes................................................................................................................................................ 20
Radiology in Gynecology ............................................................................................................. 20
For Examining Tubal Patency We Can Use.............................................................................. 20
Hysterosalpingogram (Fluroscopy)............................................................................................. 21
Indications.................................................................................................................................... 21
We Must ...................................................................................................................................... 21
If There is No Opacification There May Be: ......................................................................... 21
Complications of Hysterosalpingogram ................................................................................. 21
Abortion .......................................................................................................................................... 21
Why we prefer vaginal U/S over abdominal U/S? .............................................................. 21
Early Pregnancy Bleeding ............................................................................................................. 21
Causes ............................................................................................................................................. 21
Outpatient Gynecological drugs.................................................................................................. 22
IUCD................................................................................................................................................. 22
Bleeding .......................................................................................................................................... 22
1st/ Non- Hormonal ................................................................................................................... 22
2nd/ Hormonal ............................................................................................................................ 22
Hyperprolactinemia (Pituitary) ................................................................................................... 22
We use......................................................................................................................................... 22
Depo-provera (Medrpxy-progestrone-acetate) ..................................................................... 23
 Zoladez (LHRH analogue)............................................................................................................ 23
Climen – contain estrogen – ciproterone (anti – androgenic effect) ................................... 23
Uses .............................................................................................................................................. 23
Side effects ................................................................................................................................. 23
Danazol/ - Androgenic Effect..................................................................................................... 23
So Anti – Estrogenic effect: ...................................................................................................... 23
Side effects: ................................................................................................................................ 23
Progyluton....................................................................................................................................... 23
Contraindication ......................................................................................................................... 23
Side effects ................................................................................................................................. 24
Ectopic Pregnancy ........................................................................................................................... 24
Management .................................................................................................................................. 24
Ovarian Cyst .................................................................................................................................... 24
Functional Cyst ............................................................................................................................... 25
Functional Cyst/ Symptoms ...................................................................................................... 25
Criteria U/S ................................................................................................................................ 25
Management............................................................................................................................... 25
Follicular Cyst/ ↑ FSH. .................................................................................................................. 25
Corpus Luteal Cyst/ ...................................................................................................................... 25
Pelvic Organ Prolapse (Prolapse) ............................................................................................... 26
Prolapse/ Causes .......................................................................................................................... 26
What Are The Causes For Weak Ligament? ............................................................................ 26
Uterine Prolapse ............................................................................................................................ 26
Degree of Severity .................................................................................................................... 26
Vaginal Wall Prolapse ................................................................................................................ 26
Degree of Protrusion ................................................................................................................. 26
Symptoms .................................................................................................................................... 27
Diagnosis ..................................................................................................................................... 27
Management For Both Uterine & Vaginal Wall Prolapse ..................................................... 27
Vaginal Wall Prolapse ............................................................................................................. 27
Uterine Prolapse ........................................................................................................................ 27
Endometriosis ................................................................................................................................... 27
Causes ............................................................................................................................................. 27
 Incidence ......................................................................................................................................... 28
Presentation .................................................................................................................................... 28
In myometrium (Adenomyosis).................................................................................................. 28
Lung (rare) ................................................................................................................................... 28
Urinary bladder ......................................................................................................................... 28
Peritoneum................................................................................................................................... 28
Rectum .......................................................................................................................................... 28
On fallopian tubes..................................................................................................................... 28
On ovaries................................................................................................................................... 28
Cervix........................................................................................................................................... 28
Generally in reproductive organs .......................................................................................... 28
Diagnosis ......................................................................................................................................... 28
Grading .......................................................................................................................................... 29
Treatment ........................................................................................................................................ 29
Medical ........................................................................................................................................ 29
Surgery ........................................................................................................................................ 29
Notes .................................................................................................................................................. 29
Ovarian Cyst .................................................................................................................................. 29
Dysmenorrhea ................................................................................................................................ 29
Vaginal Discharge......................................................................................................................... 30
Physiological: .............................................................................................................................. 30
Pathological: ............................................................................................................................... 30
Pap Smear ...................................................................................................................................... 30
Miscellaneous ................................................................................................................................. 30
Semen Analysis ........................................................................................................................... 31
Useful Images .................................................................................................................................. 31
Mzhda Sahib Ja'far | Practical Gynecology
What are the conditions that gynecology deals with?
1. Menstrual cycle problems (common)
 Amount.  Regularity.  Pain.
2. Infection (PID, ……)
3. Infertility.
4. First ∆ of pregnancy (<20 weeks) or early pregnancy.
 Ectopic.  Abortion.  H. mole.
5. Endometriosis.
6. Tumors.
 Ovaries.  Uterus.  Cervix.
7. Contraception and family planning.

History Taking in Gynecology

Demographic Data
♀
Name/ GPA/
Age/ LMP/
Occupation/ EDD (if pregnancy)/
Address/ Blood group & Rh of ♀
♂
Name/ Occupation/
Age/ Blood group & Rh of ♂
Chief complaint
History of present illness
Gynecological History
1. Menstrual History
1) Menarche: Average 12 years old.
 Ranges (8-14) if secondary sexual characteristic are not present its important.
 Ranges (8-16) if secondary sexual characteristic are present so (16) is the upper
limit.
2) Menopause
 Bleeding after 1 year after menopause is abnormal.
3) Frequency of menstrual cycle (21-35) days average is 28 days.
 <21 days is frequent.  >35 days is oligomenorrhea.
Amenorrhea > 6 months no cycle.
 Primary → She has no cycle at all.
 Secondary → She had cycle but now she hadn’t > 6 months.

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4) Duration (2-7) days
5) Amount (By description of the patient and for truth we do PCV)
Menorrhagia (heavy & prolonged)
6) Dysmenorrhea. 7) IMB – Inter menstrual bleeding.
8) PCB – Post coital bleeding.
2. Contraception
 Type.  Any complication.
 How long.  Why stop.
 Route of administration.  Failure (any pregnancy).
3. History of Infertility
- Male factor infertility.
- Female factor (Tubal factor infertility, ………..).
Male (from history)
 Occupation:
 Hot environment (bakery, ……..).
 Taxi & Lori driver.  Radio grapher.
 Smoking.
 Mumps infection.  Surgery in testicles.
 Trauma to testes.  Drugs of body built.
 Undescended testes.  Diabetes.
 Tagamet (Stomach) → Anti-androgen effect.
 Whether they live together (Because the egg is fertile just for 24 hours, and
sperm for 72 hours).
 Frequency of intercourse.
Female From History
 Menstruation (Normal or not).
 Operation (where, type, size).
 Never remove a fibroid in C/S because of the risk of severe bleeding
because fibroid is very vascular and it enlarges during pregnancy but after
pregnancy it will retain its normal previous size.
 Sub serosal fibroid is ok.
 And small size other fibroids are also ok regarding fertility.
4. Vaginal discharge
 Physiological.  Pathological.
- (White, no odor, no color) it’s normal physiological discharge.
- (Green, offensive) → 𝑇𝑟𝑖𝑐ℎ𝑜𝑚𝑜𝑛𝑎𝑠 𝑣𝑎𝑔𝑖𝑛𝑎𝑙𝑖𝑠
- (Yellow, copious, offensive) → 𝑔𝑜𝑛𝑜𝑟𝑟ℎ𝑒𝑎
- (Grey, watery, fishy smell) → 𝑐ℎ𝑙𝑎𝑚𝑦𝑑𝑖𝑎
- (Cheesy, white – yellow, pruritus) → 𝑓𝑢𝑛𝑔𝑎𝑙 (𝑐𝑎𝑛𝑑𝑖𝑑𝑖𝑎𝑠𝑖𝑠)
- (Grey, watery, IMB) → 𝐶ℎ𝑙𝑎𝑚𝑦𝑑𝑖𝑎
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Mzhda Sahib Ja'far | Practical Gynecology
- (Watery, yellowish, offensive (nonspecific)) → 𝐵𝑎𝑐𝑡𝑒𝑟𝑖𝑎𝑙 𝑣𝑎𝑔𝑖𝑛𝑜𝑠𝑖𝑠
- May be asymptomatic lower abdominal pain is important.
5. Incontinence
 Urge W.C ‫ناگاتە‬  Mix  True
 Stress  Neurological  Medical problem
Urine
- Frequency. - Hematuria.
- Amount. - Odor & color of urine.
- Dysuria. - Nocturia & enuresis.
6. History of pap smear ‫فحصى شووشە‬
- Do or not. - Frequency.
- Normal or abnormal. - Any cervical problem.
7. Any prolapse
 Inside.  Outside.
Procedentia → (Complete uterus & cervix outside introitus).
Cyto cele → Bladder. Urethro cele → Urethra.
Recto cele → Rectum. Entero cele → Bowel.
8. Sexual History
 Dysparenuia
 Superficial (valve & vagina).
 Deep (Pathological).
 PID.
 Adhesion.
 Pain.  Bleeding.  Rape.
 Frequency of sexual intercourse.
Past obstetrical history Social History
Medical history Family History
Surgical history Drug, Allergy & Blood Transfusion
Examination
 Inspection.  Palpation.
Inspection
Inspection
 External (vulva, ……..).  Internal (vaginal wall, ectocervix).
Internal Inspection
Internal inspection, we use speculum:
1- Cus-cow’s speculum (Bi valve). 2- Sim’s speculum (mono valve).

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Palpation
Palpation (Bimanual Pelvic Examination).
Inserting 2 fingers into vagina and putting one hand on supra pubic region.
 Uterus:
 Size (7.5,5,2.5).
 Position (Ante bended (85%)).
(Retro Bended (15%)).
 Mobility (freely mobile). Normal Uterus
 Pain (not tender).
 Ovaries and Fallopian Tubes
 We should not feel anything by palpation ovaries (3-2-1) size
 Uterine Sound
 Before inserting any instrument to uterus we must assess the size & direction of uterus
to avoid injury.

Normal Menstrual Cycle

 Duration (3-7) days.  Amount (30-80) 50 ml average.
 Pain (24-48) hours not severe, tolerable.
 Frequency (21-35) days (28) days is average.
 After ovulation there is (0.4-0.5) degree increase (↑) in body temperature
(progesterone).
Physiology
Hypothalamus GnRh
Pituitary FSH,LH
Ovary axis

 Hormone of ovulation is progesterone because it appears after ovulation.

 Progesterone causes secretory changes in endometrium.
Fertility & Infertility
For Fertilization We Need
 Normal ovulation.  Normal genital tract.
 Normal amount & quality of sperm.  Normal functional fallopian tubes.
Types of infertility
 Primary (♀ never pregnant).
 Secondary (♀ she was pregnant but now she is infertile).
Infertility/ defined as a couple has sexual intercourse for more than or (one year) without
any protection (contraception) and the women do not get pregnant.

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 But if the female age is > 35 we should investigate if she is infertile for 6 months.
How we can know that a ♀ is fertile from history?
 Normal cycle → normal ovulation.  Infection (PID) → infertility.
 Previous pelvic surgeries (appendicitis) → adhesion and fibrosis.
 Cushing syndrome.
 Thyroid (hyper) (oligo or amenorrhea).
 Drugs → (hormones contraception).
How to investigate a woman when she is a suspected case of infertility?
 Full history.  Assess genital tract.
 Assess ovulation.  Assess the husband.
 Assess fallopian tubes.
The first step is to assess the husband by (seminal fluid analysis) because it is very simple
and noninvasive but if we start with the ♀ we may do some invasive assessment and at the
end the husband is the cause of infertility (Male factor) but here the ♂ comes at the end.
Assess Ovulation
1. Raised basal body temperature.
 We must do it for 3 months every day.
 Basal/ means when the patient wakes up even when she is on bed and no acting
and fasting.
Biphasic chart
 We have ascertain temperature in the first phase which follicular phase.
 But we have a raised temperature (0.4-0.5) degrees in the second stage or luteal
phase because of the vasodilation action of progesterone.
 Monophasic chart (no temperature change) → no ovulation.
2. U/S
 To see the dominant follicle which must have (18-22) mm near mid cycle and we
have to do 3 U/S:
1- 12th day To see follicular rupture (dominant).
2- 14th day To see ovulation and shrinkage of
3- 16th day the follicle after ovulation.
3. Progesterone: (we can measure it at 21 day because its peak>3𝒏𝒈)
4. LH: measure 36 hour before ovulation in the:
 Urine  Blood
 Biopsy (invasive) for secretory changes in endometrium by endometrial biopsy (but
not used usually).
Assess Fallopian Tubes
 Speculum:
 Polyp  Infection

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 X-ray (Hysterosalpingography): 1-2 day after menstruation (to avoid fetal harming if
the fertilization occurs)
 Laparoscopy (invasive) - GA Put at last
(Methylene blue dye) - Injury
 Thyroid and adrenal functions.

Disorders of the Menstrual Cycle

Heavy or Irregular Cycle
Causes
Gynecological
1. Estrogen secreting ovarian tumor. 5. Carcinoma of cervix.
2. Polycystic ovarian syndrome. 6. Carcinoma of vulva & vagina.
3. Endometrial polyp, carcinoma. 7. Infection.
4. Dysfunctional uterine bleeding.
 HCG Blood (𝜷 HCG) is +> 5 days of gestation.
Urine when there is Blood
Infection False +ve
Semen
 Adenexae
(Tube, Ovary & Parametrium (soft tissues & ligaments around uterus & cervix)).
Amenorrhea
Primary 16 years (if secondary sexual characteristic are present).
14 years (if secondary sexual characteristic are not present).
Secondary:- is absence of period for > 𝟔 𝒎𝒐𝒏𝒕𝒉𝒔 in a previously menstruating lady.
Primary Amenorrhea
1. Constitutional (hereditary) common.
2. Hypothalamic causes 3. Pituitary causes
 Stress.  Adenoma.
 Weight loss.  Hyperprolactinemia.
 Severe exercise.  Pan hypopituitarism.
 Tumors.  Thyroid dysfunction because of
 Trauma. pituitary.
 Idiopathic.
4. Ovarian
 Strek’s ovary or turner’s  Polycystic ovary.
syndrome.  Tumor.
5. Uterus
 Mullerian agenesis (R.K. syndrome).

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 Small uterus.  Vaginal septum.
 Absent cervix.  Imperforated hymen.
6. Systemic
 Uncontrolled DM.  Chemotherapy & radiation.
 Thyroid disorder.  Mumps.
How to approach?
- Take full history. - Height & weight.
- Examine generally (for chromosomal abnormalities).
- Family history.
- Examine visual acuity (pituitary), thyroid, mass in abdomen, hair over growth.
- Axilla & pubic hair. - Introitus to examine the hymen.
- Hormonsl level (LH, FSH, Prolactin).
- U/S (To check genital organs). - Thyroid function tests.
- Skull X-ray (Tumor, ………).
 If no problem found may constitutional so:
- Reassurance.
- Or challenge test (progesterone or combined pills).
 If any problem → treat accordingly.
It is important to treat amenorrhea a part from ovulation & fertility – for:
 Estrogen protect against osteoporosis.
 Estrogen Protect heart (MI, Atherosclerosis).
 Estrogen protect against Wrinkle skin.
Secondary Amenorrhea
Causes
 Physiological
- Pregnancy. - Lactation. - Menopause.
 Pathological
- Stress.
- Aggressive curettage (Asherman’s syndrome).
- Sheehan’s syndrome (infarction of pituitary gland) (pan hypopituitarism).
- Premature ovarian failure which occur in 1% before 40.
- Also we can add the causes of primary amenorrhea.
Also we treat accordingly.
Post-Menopausal Bleeding
- Is the bleeding after 1 year of menopause.
- Average age of menopause is 51 years old.
Causes
- Endometrial carcinoma 10% (Cancer in general).

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- Endometrial polyp 30%. - Warfarin & heparin.
- Endometrial hyperplasia 10%. - Atophic endometritis (infection).
- HRT (withdrawal bleeding). - Cervical polp & cervical carcinoma.
How to Approach?
- History. - Pap smear.
- Any mass. - Endometrial biopsy.
- Hyper estrogenism (obesity). - U/S.
- We do bimanual examination.
- Hormones
 (LH & FSH must be ↑ in menopause).
 Estrogen
Notes
- Endometrial thickness < 𝟒𝒎𝒎 exclude cancer
- Treat accordingly.
- Endometrial hyperplasia → diagnostic curettage.
- Atropic endometritis → we can use HRT if there is:
 No cardiovascular disease HT, ……….. .
 No diabetic.  No cancer (breast).
Heavy Menstrual Bleeding (Menorrhagia)
- Is excessive menstrual bleeding > 𝟖𝟎𝒎𝑳.
- 5% of ladies may have the condition that must visit outpatient clinics.
Causes
1. Idiopathic
2. Systemic
 Hypothyroidism.  Warfarin or heparin.
 DM.
 Bleeding tendency (thrombocytopenia – common).
3. Local
 Dysfunctional uterine bleeding (Unovulatory Bleeding).
 Hormonal imbalance (problem in PGs).
 Fibroid (at 30 years of age 30% of ladies may have fibroid).
 Polyp.  Polycystic ovary.
 Endometriosis.  IUCD.
How to Approach
- History. - Blood count – if anemic treat.
- Assessment (she tell true or not). - If thrombocytopenic treat.
Management
- Treat accordingly.
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- Medically
 We start by simplest NSAIDs (Mefenamic acid) →↓ Bleeding 30%
 Cyclo caprone (anti – fibrinolytic) →↓ Bleeding 50%
 Just progesterone or combined.  Anti – progesterone.
 Danazol  Zoladex – GnRH agonist.
- Surgically
 Hysterectomy.

Fertility Control (Contraception)

Types
- Hormonal. - Non hormonal.
Or
1. Natural. 3. Mechanical (IUCD).
2. Barrier. 4. Permanent (Tubal ligation).
5. Hormonal:
 Combined  Single
1. Microgynon
Microgynon (28 tabs)
- 1st yellow should be taken then brown.
- Should be used at the 1st day of menstruation.
2. HD
Not used for every cases because it contain large dose of estrogen, it’s used when:-
1) The patient take enzyme inducers like (drugs of epilepsy).
2) Also when bleeding (IMB) occurs with microgynon (after excluding chlamydia
because it causes bleeding).
3. Yasmin
HASO
H – Hirsutism. S – Sterility (infertility).
A – Amenorrhea. O – Obesity.
 Also for polycystic ovarian syndrome.
 Androcur with yasmin or Diane 35 is very helpful for greasy skin, acne, hirsutism.
 (Cyproterone acetate also can be used for men with hypersexuality because it has
anti – androgenic effect).
 > 35 𝑦𝑒𝑎𝑟𝑠, pills should be used with precautions because > 35 there is already
risk of thrombosis and ……. .
 Estrogen causes side effects (Thromboembolism) by two mechanisms:
 Hemoconcentration.  Vaso constriction.

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 Risk of thromboembolism:
 Normal population 15 in 100 000
 Contraceptive pills 30 in 100 000
 Pregnancy 60 in 100 000
4. LD
Indications
1- Irregular cycle. 4- Heavy menstruation.
2- Primary amenorrhea. 5- Polycystic ovarian syndrome.
3- Dysmenorrhea.
5. Diane 35
 Diane 35 should not be used < 18 𝑦𝑒𝑎𝑟𝑠 old.
 Liver function test should be done every 6 months.
 We don’t use it for contraception in normal ladies.
 It is used for contraception for a female with androgenization.
6. Depo – provera
- Injection.
- Long time contraception.
- (Note) if a lady gives full time lactation she has a good contraception so after 6
weeks of delivery we give contraception but without lactation we must give 1 week
after delivery.
- (Note) recurrent abortion occurs in only 1%, there is 99% chance of a normal
pregnancy.
7. (Androgen Effect) (Male Side)
- So, we cannot use it for a female with hirsitism, acne because it increases it.
8. Provera
- Provera (female side) so, it is used for some problems in a female with hirsutism,
acne ……… .
 Both of ( & provera) are not use as contraception.
9. Lenestrnol
Lenestrnol (Mini pill) ‫حەبى دایکى شیردەر‬
- Doesn’t suppress lactation.
- For old age lady who wants contraception.
- Started at 1st day of cycle. - Or 7 days after delivery.
- No waiting for menstruation, it should be used continuously.
- Within 3 hours shoulf be taken for example (4-5-6) pm.
- > 75 𝑘𝑔 One tablet is not enough, should take 2 tabs together.

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10. I-pill
- I-pill unprotected sex. - 1 tab failure of contraception.
- Within 72 hours of unprotected sex.
- If pregnancy occurred and she took the tab, it is not an indication for abortion.
11. Condom
- Condom: - contain spermicide (sometimes)
- It has a failure rate 3%
- By breakage (2,5). - By slippage (1,5).
12. HRT
- HRT – H contain natural estrogen. - So less side effects.
13. IUCD
 IUCD Non hormonal (copper loaded) copper T.
Hormonal (Merena) progesterone loaded.
 We do IUCD immediately after the menstruation because we are sure that there is no
fetus & cervix is slightly opened because of previous menstruation, sterile.
Contraindication
1. Pregnancy. 3. Acute infection (PID).
2. Undiagnosed vaginal bleeding. 4. Sensitivity to copper.
Complications
1. Pain. 3. Infection →↑ chance of PID for
2. Bleeding – irregular vaginal 3 weeks.
bleeding. 4. Perforation.
5. Tubal block & infertility (Late).
Notes
 At any time we can remove it.  Should be removed every 5 year.
 Merena should be removed every 3 years.
Failure Rate
- 0.5% 1 in 200 cases & when pregnancy occurs it (IUCD) increases the chance of
ectopic pregnancy.
Mechanism
- Local inflammation. - Reduce sperm motility.
- So no more fertilization & pregnancy.
Notes on Intrauterine Device (IUD) (Copper T)
- For (4) months may have irregular cycles, bleeding.
- If infection occurs within 20 days of inserting IUD so it is caused by the IUD.
- If the patient asked about sexual intercourse after IUD you can say:

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 If the patient has no blood she can have intercourse.
 If there is blood/ not sexual intercourse.
14. Merena (Hormonal IUD).
- The green piece is the reservoir for the hormone.
- The hormone is levongesterol (Progesterone).
Its Action
- Thining of endometrium so the ovum cannot be implanted.
Indications
1. Contraception.
2. Some other treatments like:
1) HRT. 5) Endometrial hyperplasia.
2) Regulate menstrual cycles. 6) Dysfunctional uterine
3) Amenorrhea. bleeding.
4) Emdomeriosis. 7) Premenstrual syndrome.
 It has less side effects/ because it works locally.
Note on contraceptive pills generally
- ↑ Risk of breast & cervical carcinoma.
- But ↓ risk or it is good for ovarian & endometrial carcinoma.
- Ring picery/ temporary treatment (Management) for vaginal prolapse.
- Emergency contraception I-pill (within 72 hours).
IUD (5 days).
HD as emergency (now 2 tab after 12 hours another 2 tab).
- After menopause of a lady < 50 𝑦𝑒𝑎𝑟𝑠 we should give 2 years of contraception
(because there is a chance for pregnancy) even without menstruation.
- After menopause of a lady > 50 𝑦𝑒𝑎𝑟𝑠, also we should give 1 year contraception.

Abortion
 Abortion < 20 weeks Some said 24 weeks
 I.U.F.D > 20 weeks
Types
1. Threatened Abortion
- Fetus is viable. - 50% may continue.
- Cervix is closed.
- Slight pain & slight discharge (blood).
2. Incomplete Abortion
- Part of the fetus & placenta - Profuse vaginal bleeding.
remain. - Dilated cervix (open os).
- Severe lower abdominal pain.

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 < 12 weeks (first ∆ abortion) → Medical & surgical
 > 12 − 20 weeks (second ∆ abortion) → Just only medical
 It is important to differentiate because the model & management is different.
 We cannot use curettage for women with 2nd ∆ abortion we use medical way
(Misoprostol)
 Misoprostol → Prostaglandin 𝐸1 analogue.
3. Induced Abortion 4. Missed abortion (Miscarriage)
- At hospital. - Loss sign & symptom of
- Septic (infection →↑ pregnancy.
prostaglandin). - No fetal heart pulsation.
5. Complete Abortion
Types of Abortion & Their Characteristics
Type Clinical U/S Cervix
- Slight to mild
vaginal - Gestational sac - Closed.
1- Threatened bleeding. is healthy. - Slight vaginal
- Painless or - FHR is +ve bleeding.
slight pain.
- Moderate to
severe vaginal
bleeding - The sac
disrupted. - Opened.
(sometime with
2- Incomplete shock), clots. - Multiple - Pieces of fetus
retained piece. & placenta.
- Severe crampy
lower - FHR is –ve
abdominal
pain.
- Heavy amount - Empty uterine
of blood. cavity.
- Closed.
- Severe pain. - Slight
3- Complete - Slight vaginal
- But now both of endometrial
thickening. bleeding.
them
subdivided. - FHR is –ve
- Sometimes
accidentally
detected, no
pain.
- The sac is
- Brown slight healthy. - Closed.
4- Missed
vaginal - Slight bleeding.
bleeding. - FHR is –ve
- Loss of sign &
symptom of
pregnancy.

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 Induced abortion/ legally or illegally
 Endometrial thickness
- < 4𝑚𝑚 (after menstruation). - 10-15 mm (in luteal phase).
 Inevitable abortion
- FHR +ve. - Bleeding increase.
- Cervix opened.
Causes
1. 30% having chromosomal abnormalities.
2. 30% having congenital abnormalities.
3. Endocrine disease (Cushing’s, hypothyroidism).
4. Infection (TORCH).
5. Medical diseases of the mother (HT, DM, chronic renal disease).
6. Drugs (cytotoxins, chemotherapy), radiation and insecticide or pesticide.
7. Trauma.
8. Diseases of placenta (Anti – phospholipid syndrome).
9. Congenital abnormalities of genital organs (abnormal uterus).
10. Extremes of age < 𝟏𝟖 & > 𝟑𝟓 11. Fibroid in uterus
12. Some resources said (Group A) blood more susceptible.
Management
 Conservative.
 Follow up, may continue to complete abortion.
 Medical
 Misoprostol, oxytocin, Mefipristone.
 Which is anti – progesterone, cervical dilatation.
 Surgical
 Curettage or dilatation & curettage (D & C).
Recurrent Miscarriage (hospital abortion) it means 3 consecutive abortions, incidence 1%.
D & C/ can be used Diagnostically (Endometrial biopsy)
Therapeutically (Abortion)
Missed – Miscarriage
- Admitt - ABC.
- Shocked or not (Resuscitation).
- 2 wide bore cannula (IV fluid crystalloid more important that colloid).
- Take blood for investigations. - IV fluid (to maintain circulation).
- When blood prepared give blood if needed.
- And check for the cause of the abortion.

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Threatened abortion
- Rest. - Treat infection.
- Conservative. - Good food.
- Treat anemia. - Follow up is important.
Incomplete miscarriage
- Emergency situation. - Treat anemia.
- Prepare for anesthesia. - Do curettage.
- Give Antibiotics.
 Septic abortion Spontaneous
Induced
 Induced Legal
Illegal
Legal
- For sake of mother (breast & - Congenital anomalies (2nd ∆).
cervical cancer). - Down syndrome not regarded as
- Missed miscarriage. legal here.
Illegal
- Admit. - After 12 hours of giving antibiotics,
- Resuscitation (ABC) septicemic shock. evacuate the uterus.
- Treat septicemia. - Sometimes we give hydrocortisone 3
- Good antibiotic coverage. mg (causes vasodilatation).
- Plenty of fluid (renal shut down).
Illegal subsequent
- Death. - DIC and death.
- Renal shut down. - Tubal blockage & infertility.
Septic miscarriage
- Admit. - Swab from vagina, rectum, urethra.
- Resuscitate. - Blood investigations.
 If there is severe bleeding so we do evacuation & give ABs.
 But if no bleeding or slight so we give Abs for 24 hours and then evacuation.
 In all types for a woman with Rh-ve we give Anti – D.
Religious Abortion
 Life threatening to the mother (Breast  Severe lethal congenital anomalies
cancer). (anencephalus, hydrocephalus).
 But meningocele (not allowed).
Management of a Woman With Miscarriage
 Threatened → doing U/S, reassurance

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 Inevitable → admit  Incomplete → Medical or Curettage.
 Complete
- AB - Analgesia. - U/S.
 Missed miscarriage → Medical or surgical.
Misoprostol
 Misoprostol (Misotec or cytotec)
- Uterotonic. - 1 tab is 200 𝜇𝑔.
(< 𝟏𝟐 𝒘𝒆𝒆𝒌𝒔)
 Orally/ loading dose every 3 hours / 2 tabs
/ 3 tabs
/ 3 tabs 4 doses
/ 3 tabs
 If no response → next day
No loading dose so 3 tabs
3 tabs 3 doses
3 tabs
 If no response → Evacuation
(> 𝟏𝟐 𝒘𝒆𝒆𝒌𝒔)
 ( 2 tab vaginally every 4 hours)
- 4 times. - So 4 doses.
Side effects of misoprostol
- Pain – Give analgesia. - Allergy.
- Bleeding. - Bronchospasm.
Should be in hospital.
Requirements for Curettage
1- General anesthesia. 4- Full aseptic condition.
2- Should be in operative theatre. 5- Good light source.
3- In lithotomy position. 6- Good assistant.
 If 6 weeks missed period lady comes to you by U/S there is no FHR
- If there is any infection (treat it). - Vaginal U/S.
- Searching again after 10-14 days to check viability of the fetus to confirm pregnancy.
 Missed – miscarriage Medical
Surgical
Medical is better than surgical because:-
- Less pain. - Less infection. - No perforation.
- Less bleeding. - Less costy.
- No side effects of anesthetic agents.
Medical → Mostly misoprostol.
Surgical → Curettage or D & C.

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What Are The Steps For Doing Curettage?
1- Inspection (external genitalia). 2- Sterilization & toweling.
3- EVA/ examination under anesthesia (so we can do deep palpation and search for
abnormalities).
4- Speculum. 5- Inspection (internal genitalia).
6- Volesellum. 7- Uterine sound.
8- Dilator (Hegar’s dilator) (if cervix closed) till 8 mm.
9- Sponge. 10- Curate.
11- Assess bleeding (if severe blood loss and needed must be replaced by fluid or
blood).
 Pathological retroverted uterus (if there is a big fibroid).

D & C (Dilatation & Curettage)

 Lithotomy position (Widest Pelvic Diameter):
 Pap  Curettage  Biopsy
- Lithotomy bed.
- Dram (pressure gloves, ……….).
- Troly (Table for moving equipments) (‫)ئەو مێزەى کە ئەجوڵێ‬.
- Kidney dish (Preserving instruments, sometimes to put the bloody and dirty things
into it).
- Iodine & hibitin – antiseptic.
- Volleselum (catch anterior lip of the cervix in order to introduce instruments to the cervix
& uterus.
- Sound (Uterine length in weeks).
 Length by sound is 6 cm → 6 weeks (because of wall)
Cervix is (2.5-3.5 cm in length).
 We have corpus of uterus & cervix.
 Weight (Normal 𝟕𝟎 𝒈𝒎 – pregnant 𝟏 𝒌𝒈).
 Endometrial cavity is a triangular space.
- Hegar dilator/ if cervix is not dilated, short from 2 mm …….. > 12 𝑚𝑚
- Sponge/ to hold any tissue.
- Curate/ for curettage
 Sharp  Blunt (1st used)  Mix
 We feel crackle sensation.
 We see air bubble comes from cervix. So we are finished with curettage.
Left lateral position/ for utero vaginal prolapse, we use mono blade speculum and ask
the patient to do a strain then we see the prolapses part which is moving.

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 Cus – cow’s speculum (Bi blade):
 Pap  Biopsy
 Cervix  Entering instrument
 Mono blade (Sim’s speculum) for prolapse and sometimes we can use it for other
purposes also we have different sizes.
Ergometrin
 Ampoule – we call it ergot really it is Methyl ergometrin.
 Route of administration is IM, IV.
 Each ampule is composed of 0.2 mg.
 We use 2 ampoules so 0.4 mg.
 It is utero tonic:
 Incomplete abortion.  To induce uterine spasm.
 Missed Miscarriage.  To prevent or stop PPH.
 To prevent or stop post curettage bleeding.
 We must not use it in pregnancy;
 In early → lead to miscarriage.  In late → uterine rupture.
 It causes severe nausea & vomiting especially when used (IV) because of its vascular
spasm effect.
Contraindications of Ergometrin
 Heart disease.  Asthma.
 Hypertension.  Pre-eclampsia.
What are the complications of curettage?
Immediate
1. Injury (cervical injury → cervical incompetence).
2. Uterine Perforation
 Sharp (Mostly).  Sound.
3. Bleeding (severe). 6. Severe pain (neurogenic shock).
4. Injury to bladder or bowel. 7. Infection.
5. Incomplete evacuation. 8. Complication of GA.
Late
- Adhesion (Asherman’s Syndrome) (Endometritis)
 Adhesion of endometrial cavity (Infertility).
 Tubal blockage:
 Chronic pelvic pain.  Ectopic pregnancy.
Some Notes
 After evacuation and cleaning the uterine cavity we can use antiseptic.
 And we use Antibiotic.
 Flagyl (Anaerobes)  Doxycycline

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 Also pain killer (Mefenamic acid) also stop bleeding.
 We advise a suitable contraception.  We advise good hygiene.
 20% of all pregnancies will lead to miscarriage.

Trophoblastic Diseases
Types:
- Molar (hydatiform mole). - Chroriocarcinoma.
- Persistent.
Presentation:-
- Asymptomatic - Big for date.
- Bilateral big ovarian cyst (HCG) ovarian stimulator.
- Profuse vaginal bleeding.
- Exaggerated sign & symptom of pregnancy.
Trophoblastic disease Partial.
Complete (↑ risk of choriocarcinoma).
Diagnosis
- U/S → snow storm ‫العاصفە الثلجیە‬
- When we see it is like ‫هێشوەترێ العنقود العنب‬

Causes
- Is genetic, abnormal fertilization. - Normal ovum & 2 sperm/ complete.
- Abnormal (empty) & 2 sperm/ partial.
So double paternal chromosomal material.
There is a risk to have another trophoblastic disease in subsequent pregnancies.
Treatment
- Previously → hysterectomy

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- Nowadays/
 1st stage - (evacuation – suction curettage).
 2nd stage chemotherapy (Methotrexate) (Anti – metabolite).
 3rd stage – follow up (𝜷 HCG) Tumor marker.
Follow Up
- We must have a baseline 𝛽 HCG.
- Within three days of evacuation should be dropped 40-50%.
- Every 3 day until – 2 𝐼𝑈⁄𝐿.
- After that it must be 2 𝐼𝑈⁄𝐿 in 3 times for 3 weeks.
- After that every 1 month till 3 months.
- After that 6 -1 year.
 We must give folic acid with methotrexate (because the body of the patient need folic
acid).
8 days course.
 Every other day we give Methotrexate 4 doses.
 Every other day we give folic acid important for DNA.
Notes
 Evacuation of H. mole is very risky & dangerous because the uterus is big and at that
time it is very vascular and complete to bleed …………. .
 Before giving chemotherapy (Methotrexate) we must do:
- Complete blood count (Aplastic – pancytopenia).
- Liver function test.
 Difference between mole & choriocarcinoma is that mole contain (villi) like normal
placenta but choriocarcinoma contain sheets of trophoblasts and there is no (villi).
 Choriocarcinoma/
- For young chemotherapy. - For old total hysterectomy.

Radiology in Gynecology
 Plain X-ray for ovarian cyst + if it is dermoid there is teeth or a piece of bone.
- We can use iodine as (Contrast). - IVU → Intravenous urography.
For Examining Tubal Patency We Can Use
- Hystereosalpingogram.
- Laparoscope under GA by using methylene blue dye it is superior to
Hysterosalpingogram in that:-
 To define peritoneal causes of infertility like (endometriosis)
- Polycystic ovary.

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Hysterosalpingogram (Fluroscopy)
Indications
1. Infertility.
2. Congenital anomalies of genital tract.
3. Post – ectopic pregnancy.
4. Habitual abortion (3 successive abortion).
 Abnormal uterus.  Cervical incompetence.
 We must do it in follicular phase at day 9 or 10 after menstruation to avoid
endometriosis, also we should give Antibiotics before the investigation till 5 days
following the investigation.
We Must
1. Exclude pregnancy. 2. Sensitivity to drugs.
3. Exclude active genital fract (give treatment).
If There is No Opacification There May Be:
- Early radiogram. - Closed tubes (non-patent tubes).
Complications of Hysterosalpingogram
1. Painful (we must give analgesia like Voltaren, paracetamol & or pethidine)
2. Injury to cervix by the uterine cannula.
3. Bleeding. 4. Infection (Septicemia)
5. Allergy to drugs.
Abortion
- History.
- Vaginal U/S (always it is used for 1st ∆ problems).
Why we prefer vaginal U/S over abdominal U/S?
1- FHR is detected vaginally earlier that abdominal.
2- Gestational age. 3- Multiplicity of pregnancy.
4- Intra or extra uterine pregnancy.
5- Diagnose H. mole (Trophoblastic disease).
6- Cervical incompetence (the real measurement).
 But in abdominal U/S we need full bladder and this cause cervical stretching so false
results.

Early Pregnancy Bleeding

 Exclude pregnancy
Causes
Pregnancy related Non pregnancy related
1- Miscarriage (Abortion) 1- Genital injury
2- Ectopic 2- Local (Infection)
3- GIT bleeding from rectum, Bleeding
3- Trophoblastic disease (H. mole)
hemorrhoid .

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Outpatient Gynecological drugs
IUCD
IUCD Hormonal (Merena).
Non hormonal (Copper T).
Bleeding
For bleeding Menorrhagia
Dysfunctional uterine bleeding We use.
1st/ Non- Hormonal
1. Exacyl (Anti-Fibrinolytic) – cyclo caprone 500 mg (at least 2 gm to stop bleeding 4
tab/day).
2. Mefenamic acid (Ponistan)
 Prostaglandin 𝐼2 synthase inhibitor.
 It is NSAIDs.
2 / Hormonal
nd

1. Normolute – N (Progestrone) – 5mg (weak androgenic effect)

We can use it: Cyclical 5-26 day → To stop bleeding.
Leuteal 16-26 day → Premenstrual tension.
→ Dysmenorrhea.
→ Regulate cycle.
→ Dysfunctional uterine bleeding.
2. Clomifen (Clomid) or Tamoxifen (tab) (anti-estrogen).
 (day 2 – day 5 after menstruation).
 Follow up by vaginal U/S (13th) day → Ripening follicle (18-22 mm).
 If after administering (Clomifen) at day 13th → There is a ripening follicle (18-22 mm)
so we can use LH Surge by (Prygnil) (HCG) → Which is Human Chorionic Gonadotropin
(HCG) 6500 IU, for ovulation (5-10) 000 (32-36 hours).
3. Gonal – F (FSH) injectable.
 Day 2-5 after menstruation.  Multiple Pregnancy.
 Expensive.
Hyperprolactinemia (Pituitary)
 For hyper prolactenemia (Pituitary)  Failure of ovulation → infertility.
We use
1. Parlodyl → Bromocryptine (dopamine agonist)
 To suppress prolactin production.
- Regulate cycle.
- To inhibit lactation after (IUFD) for 2 weeks.
 2.5 𝜇𝑔⁄𝑡𝑎𝑏 7.5 mg/day.
 Side effects/ Severe gastric upset.

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2. Dostinex (cabargolin)
 Expensive.  Every 3 day/1 tab.
 Less Side effects.
Depo-provera (Medrpxy-progestrone-acetate)
- As a contraception. - Injection for 3 months.
Zoladez (LHRH analogue)
 Severe dysfunctional uterine bleeding.
 Uterine fibroid (shrinkage before surgery).
 Severe Menorrhagia.
 Side effects:
 Induce menopausal sign & symptom (Iatrogenic Menopause).
 Like:
- Back pain. - Absence of menstruation.
- Hot flushes. - Dry vagina.
Climen – contain estrogen – ciproterone (anti – androgenic effect)
Dian 35 has the same complications of Climen.
Uses
1. Hormone replacement therapy.
2. Hirsutism. 3. Regulation of the cycle.
Side effects
 Teratogenic effect (climen)
Danazol/ - Androgenic Effect
So Anti – Estrogenic effect:
 Fibroid.  Dysfunctional uterine bleeding.
 Most important for endometriosis.
Side effects:
- Obesity. - Hirsutism. - Even diabetes.
Progyluton
 Progyluton: it contain 2 tablets (while is estradiol valerate 2 mg and light brown
estradiol valerate 2 mg with nergestril 0.5 mg), estradiol valerate is a natural
estrogen, uses (after removal of ovary or costration by irradiation, irregularity of the
cycle, and amenorrhea).
Contraindication
 Pregnancy.  SCA.  Hormone Dependent
 Thrombosis.  Endometriosis. Tumor.

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Side effects
 Tension In Breasts.  Headache.
 Stomach Upset.  Influence of body weight and sexual
 Nausea. drive.

Ectopic Pregnancy
 Is the implantation of a fertilized egg outside to the uterine cavity or endometrium of
uterus.
- At (8-10 weeks) of gestation, if a lady with pain & bleeding, we think of ectopic
mostly.
- But if the ectopic is in the rudimentary horn, it may continue to 16 weeks, and then the
horn will rupture and she comes with shock, bloated abdomen, …………. .
- Normally 𝛽 HCG is > 𝟏𝟓𝟎𝟎 at 5th week.
- If we have for example 1400 → we do U/S.
- After that another HCG → If HCG doubled so normal pregnancy.
→ If HCG not increased so ectopic or abnormal (miscarriage).
- And then laparoscopy.
- So the most useful modalities for ectopic are:
 U/S.  HCG level.  Laparoscopy.
Management
1. Conservative:
 If the fetus not viable.  Tube not ruptured.
 < 3𝑐𝑚.  No hemoperitonium.
 We give her methotrexate (single or multiple) doses.
 Follow up important by vaginal U/S and 𝜷 HCG.
2. Laparoscopy
- Salpingotomy. - Salpingectomy.
 Areas outer uterus for ectopic
 90% in tubes.
 10%
 ovaries.  Abdominal cavity.
 Cervix.
 Up to 10% may have recurrent ectopic.
 If the other tube is patent she has chance to be pregnant but less chance.

Ovarian Cyst
 Polycystic ovarian syndrome is different from ovarian cysts:
- It is a group of features (syndrome).
- Small cyst on ovary (they are not actual cyst).

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 Ovarian Cyst Functional temporary cyst
Actual ovarian tumor (Benign & malignant) (may need
surgical intervention).
 Cyst> 3𝑐𝑚
Functional Cyst
 Functional/a cyst develops from disturbance of normal function of ovaries. (grow
follicles & rupture (ovulation)).
Functional Cyst/ Symptoms
- Mostly no symptom, it may be diagnosed by U/S.
- May disturb menstrual cycle.
- The case present with acute abdomen
 Rupture.  Infection.
 Hemorrhage.  Torsion.
Criteria U/S
- Must be completely cystic lesions (it contain only fluid so (black) on U/S).
- The surrounding membrane or capsule must be regular and very thin.
- Size shouldn’t exceed 10 cm.
Management
 depends on:
 Size.  Asymptomatic or not.
 Mostly disappear with time (18-12 weeks) ↓ in size or subside, if not we can wait if the
size not increasing.
 We must do urgent laparotomy for those with acute symptoms.
 In H. mole we must treat the cause by evacuate the uterine cavity so ↓ HCG → cyst
subsides, if acute symptoms occurs we must treat the cyst.
 If the cause of the cyst is external FSH we must stop it & observe.
Follicular Cyst/ ↑ FSH.
 Naturally (the follicle because of some reasons don’t rupture and continue to grow
until reach a cyst size).
 Externally giving FSH (when we give FSH to an infertile woman may over stimulate
the ovaries and produce follicular cyst).
 H. mole (theca – leution cyst) (in H. mole there is ↑ HCG which is over stimulate
ovaries and causing cyst formation).
Corpus Luteal Cyst/
 Also maybe by some reasons grow and produce a cyst.

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Pelvic Organ Prolapse (Prolapse)
- Is protrusion or downward movement of an organ from its normal place wither to
another area or to exterior.
- Genital tract prolapse we have two types:
 Uterine / Uterine prolapse.  Vagina / Vaginal prolapse.
 OR Uterovaginal Prolapse.
 Genital tract prolapse is not a life threatening condition.
- Ligaments that fix the uterus:-
1- Transverse cervical ligament (cardinal) laterally to pelvic bones.
2- Uterosacral (posteriorly) to sacrum.
3- Broad ligament (not so important because actually it is a twofold of
peritoneum).
4- Round ligament (it is weak) from fundus to inguinal canal to labia majora.
Prolapse/ Causes
 By weakness of those ligaments that support the uterus.
What Are The Causes For Weak Ligament?
1- Previous multiple pregnancy & labor especially difficult labor.
2- Age (after menopause is more likely).
3- Chronic increase in intra-abdominal pressure, like:
- Cough and constipation. - Morbid obesity.
- Ascites. - Big abdominal mass.
4- Congenital weakness of collagen.
Uterine Prolapse
Degree of Severity
- 1st/ down ward moving of uterus to the middle of vagina.
- 2nd/ cervix appear at introitus (may protrude when the patient push).
- 3rd/ all the cervix & uterus outside we call it (procedentia), usually accompanied with
vaginal wall prolapse.
Vaginal Wall Prolapse
- Anterior vaginal wall prolapse (the structures like bladder & urethra which are anterior
to the vagina may protrude to the vagina, so depending on the structure (cytocele,
urethrocele or cytourethrocele (mostly))).
- Posterior vaginal wall prolapse (the structures like rectum % bowel also may protrude
due to lax posterior vaginal wall so (rectocele or enterocele).
Degree of Protrusion
 Mild (small part of structures).  Severe (very big structures).
 Moderate (not very large).

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Symptoms
- Mild prolapse mostly asymptomatic. - Heaviness in pelvis & vagina.
- Protruding of a cyst during urination.
- Not affect menstruation (physiologically).
- Some difficulty during menstruation. - Difficulty in passing stool.
- Urinary symptoms (frequency, urgency, incontinence, urinary retention, recurrent UTI)
- Bach pain because of pressure on ligaments which contain nerves especially at the end
of the day (tired) and relieved by lying down.
Diagnosis
- History.
- Most of the time clinically by inspection we can diagnose even the types of the
prolapse so we don’t need and not using other investigations.
- Also we can do GUE to exclude UTI before.
- IVP (Intravenous pyelogram).
Management For Both Uterine & Vaginal Wall Prolapse
Depends on:
- Age - Parity. - Severity.
 Mild not treated (not symptomatic) just by physiotherapy for strengthening of the
muscles.
 Sometimes moderate also we don’t do surgery just accordingly.
- In severe type & if needed in others (mild & moderate) we can do surgery, type of
surgery depends on the type of prolapse:-
Vaginal Wall Prolapse
- Anterior colporrhaphy (vaginal repair) we remove the lax wall and suture the wall.
- Or posterior colporrhaphy.
Uterine Prolapse
- Fixation (Manchester operation) (we repair the transverse cervical ligament).
- Remove (hysterectomy) vaginally.
 Procedentia/ the best is hysterectomy if the patient fit for operation if not because of
diseases or very old we can use (ring picery) to fix vagina so the uterus cannot come to
vagina.
 Sometimes after hysterectomy (abdominally or vaginally) when we remove the uterus
we suture the upper vagina (we call it – Volt- of the vagina) after 1 – 2 year (1 in
200 of cases) having volt prolapse – also we can fix it to bones by mesh.

Endometriosis
 It is implantation of endometrium outside the uterine cavity.
Causes
We don’t know the definitive cause but:-
1- Retrograde menstruation. 2- Hematological spread.

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3- Lymphatic spread.
4- Or maybe embryological.
Incidence
We don’t know but here may be 10 cases in one year.
- White slim Caucasians ladies are more risky.
- Running in families. - Not cancer & not malignant.
Presentation
In myometrium (Adenomyosis)
 Dysmenorrhea, IMB, prolonged period.
 Bulky uterus, menorrhagia.
 Difficulty to be pregnant. (irregular prolonged bleeding)
Lung (rare) Urinary bladder
 Periodical hemoptysis.  Periodical hematuria.
 Chest pain.  Dysuria.
 Dysmenorrhea.
Peritoneum
 Adhesions.
 Tubal blockage Infertility.
 Dysmenorrhea.
Why they have painful sex/ because adhesions causes immobile retrograde uterus in pouch
of Douglas.
Rectum On fallopian tubes
 Periodic rectal bleeding.  Pain.
 Painful defecation.  Adhesions.
 Fissure.  Infertility.
 ↑ Risk of ectopic pregnancy.
On ovaries
 Chocolate cyst (endometrioma)
- Asymptomatic or - Rupture.
- Torsion. - Hemorrhage.
Cervix
 Painful sex.  PCB.
Generally in reproductive organs
 Dysmenorrhea.  IMB.  Irregular cycle.
 Dyspareunia.  Menorrhagia.
 Laparoscopy & biopsy is gold standard
Diagnosis
- Clinical feature - U/S (chocolate cyst).

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- Hydrosonography.
 Lab test not helpful.
- Laparoscopy and biopsy gold standard.
- Ca – 125 →↑ but not specific.
Grading
 𝐺1 Mild  𝐺1 Mild
 𝐺1 Mild  𝐺4 Very severe
The amount doesn’t tell the severity
Treatment
Medical
 Paracetamol or paracetamol + codeine (codeidomol).
 NSAIDs (before the pain starting).
 Hormonal (combined or progesterone alone).
- 5th of her period. - And a break.
- Continue for 3 months (back to - Also we can give monthly.
back). - We can give depo – provera.
 Zoladex – (temporary for 6 months).
We can use it as test before surgery if it works so the surgery is also help.
Surgery
 Laparoscopy Diagnostic
Therapeutic
(hysterectomy and bilateral salpingo – oophorectomy) .

Notes
 Polycystic ovarian syndrome → hormonal.
Ovarian Cyst
 Functional or Physiological
 Follicular cyst.  Corpus luteal cyst.
 Pathological (dermoid,……..)
 Ovarian Cyst
 Benign - Dermoid → Very rarely → Malignant (terato sarcoma)
 Enlarges with age.  Congenitally in the ovary.
 Contain germ cells.
 Malignant.
Dysmenorrhea
1. Primary (physiological) → pain during the first 24 hours of menstruation and decrease
↓ after that it is like an ischemic pain because the basic of menstruation is ischemia
(vascular spasm) of uterus.

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2. Secondary (pathological) → starts before menstruation, it is a dull pain and continue.
Vaginal Discharge
Physiological:
1. Premenstrual. 3. Pregnancy.
2. Ovulation time. 4. During sexual (arousal) contact.
Pathological:
1. At any time. 3. Odor.
2. Different colors. 4. Itchiness.
Pap Smear
 A screening test.  Cytological examination.
 Swab from cervix.
 For CIN (Cervical intra-epithelial neoplasia).
 Irispetula/ swab from ecto & endo cervix.
 Brush cytology/ immediately for histopathology.
 Colposcopy/ microscope for seeing cervix, if abnormal so biopsy to see:
 Normal.  Dysplasia .
 Metaplasia.  Neoplasia.
 HPV6 → STD
 99% of cervical cancer have + HPV but minority of those who have + HPV have
cervical cancer.
 IMB.
 PCB.
 Chronic VD. Pap smear
 Suspicious cervix.
 During examination.
 If Pap smear is +ve we must do another test which is (colposcopy)
 IMB Infection
Tenderness By exam
Mass
 Also for IMB we do transvaginal US.
 Regular heavy cycle → Menorrhagia.
 Irregular heavy cycle → Menometrorrhagea.
Miscellaneous
 Anti – D is remain or it is active and useful for 6 weeks when it is given to a women
before that <6 week we don’t need another dose if the patient need to have or to
give Anti – D because already she is immunized for 6 weeks.
 But after that >6 weeks we must give another dose when it is needed for any
procedure, abortion, bleeding.

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 There is no limit for Anti – D administration because when it is need to be given > 6
weeks we must give it to the patient.
 Age> 35 old primi gravida it increases the chance of:-
1. Infertility. 4. Abnormal bleeding.
2. Miscarriage. 5. Fibroid.
3. Menorrhagia.
Semen Analysis
 Semen analysis (World Health Organization) reference values Gynecology by ten
teachers.
 Volume:- 2-5 mL.
 Liquifization time:- within 30 minutes.
 Sperm concentration:- 20 million/mL.
 Sperm motility: > 𝟓𝟎% progressive motility.
 Sperm morphology: > 𝟑𝟎% normal forms.
 WBC:- < 𝟏 𝒎𝒊𝒍𝒍𝒊𝒐𝒏⁄𝒎𝑳.

Useful Images

(a) Cusco’s speculum; (b) Cusco’s speculum in position. The speculum should be inserted at about 45° to the vertical and
rotated to the vertical as it is introduced. Once it is fully inserted, the blades should be opened up to visualize the
cervix.

(a) Sim’s speculum; (b) Sim’s speculum inserted with the patient in the left lateral position. The speculum is being used to
hold back the posterior vaginal walls to allow inspection of the anterior wall and vault. The speculum can be rotated
180° or withdrawn slowly to visualize the posterior wall.

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(a) Bimanual examination of the pelvis assessing the uterine position and size; (b) bimanual examination of the lateral
fornix.

Tanner staging.

Changes in hormone levels, endometrium and follicle development

Hypothalamo–pituitary–ovarian axis. during the menstrual cycle.

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Pipelle endometrial sampler.

Hysteroscope.

The levonorgestrel intrauterine system (LNG-IUS, Mirena).

Microwave endometrial ablation probe (Microsulis).

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Gross appearance of polycystic ovary. Ultrasound picture of polycystic ovary.

Combined oral contraceptive pill preparations. Monitoring blood pressure in a woman taking the
combined oral contraceptive pill.

Combined vaginal ring. Combined vaginal ring.

Combined contraceptive patch.

Progestogen-only pill preparations.

Depo-Provera.

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Implanon. Implanon.

Insertion position of Implanon. Intrauterine device (IUD) in the uterine cavity.

Hormone-releasing intrauterine system – Mirena.

Copper bearing IUD with copper on stem and arms.

Diaphragms.

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Vault prolapse Uterovaginal prolapse

Varieties of prolapse.

A rectocele Ring pessary. Shelf pessary.

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Treatment of prolapse.

New mesh kit for prolapse.

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