GYNA REVISION NMT11

INDEX

Topic Page
History & Examination 3
Anatomy 4
Development 6
Menstrual cycle 7
Menopause ,amenorrhea & disorders of 9
menstrual cycle
Abnormal uterine bleeding ,disorders of 13
ovulation & PCOs
Hirsutism, lower genital tract infections 17
& PID
perineal lacerations & recto vaginal 21
fistula
STD, T.B., bilharziasis 23
Infertility 26
Endometriosis 31
Prolapse 33
Urology 37
Non neoplastic cysts 45
Diseases of the vulva & vagina 50
Choricarcinoma 54
Fibroids 55
cancer cervix 60
Endometrial carcinoma 69
Ovarian neoplasms 70
Contraception 76
diagnostic procedures 78

2
 GYNA REVISION NMT11

Gynecological history & examination

Exam questions

indications of rectal examination in gynecology (Feb 98)

the sexual history ( Feb 2004)

the menstrual history ( may 2004)
for mcqs
o the Points determined during a bimanual examination
1. Size :Normally hardly felt (7.5 × 3.5 cm in long & A.P. diameters)
2. Shape: Normally pear shaped with smooth outer contour
3. Position: AVF in at least 80 % of women ,RVF in < 20% .the direction of the cervix is an excellent
indicator for the position of the uterus. In AVF uterus the cervix is directed towards the posterior
fornix and in RVF towards the anterior fornix .If the uterus is retroflexed it cannot be felt
bimanually, but the fundus can be felt through the posterior fornix
4. Mobility : normally the uterus is mobile except if fixed with adhesions
5. Tenderness on the pressure or on movement: The normal uterus is slightly tender when
squeezed between the two hands
6. Palpation of the lateral fornices by fingers on the right hand while the left hand is placed lateral
to the uterus in an attempt to palpate the adenxa between the fingers both hands .normal tubes
are never palpable ,even in the anaesthetized patient .palpation of ovaries is largely a matter of
chance but if they are not felt the gynecologist can be reasonably certain that they are not
enlarged
7. Combined vaginal & rectal examination
o rectal examination
important IN
1. Examination of virgins
2. In cancer cervix “to asses extension to parametrium along the uterosacral ligament”
3. In cases of prolapse “to asses whether there is rectocele or not “
4. Cases with complete perineal tears if diagnosis is not sure by inspection alone
5. Cases with mass in douglas pouch
6. Cases with postmenopausal bleeding (piles, cancer rectum)
7. Any patient complaining of rectal symptoms
o EUA(examination under anaesthesia)
when pelvic examination is difficult or impossible (E.G. because of virginity), examination will be
made easier with relaxed patients abdominal wall & vaginal introitus yielding better data for
diagnosis
o SONAR: the word stands for “sound navigation and ranging “

3
 GYNA REVISION NMT11

Anatomy
Exam questions

Anatomy of the pelvis (july 95,feb 97,feb 99)

Anatomy of the vagina (March 94 )

Anatomy of the uterine ligaments(june 99,june 2001)

Mackenrodt’s ligament(feb 97)
For mcqs
o some special characters of labia minora
Labia minora vary in size & larger in children; they contain loose C.T devoid of fat & are very vascular
to become turgid during coitus, hairless as Inner medial surface of labia majora
o length of female urethra
4 cm
o Internal pudendal artery ends as
The dorsal artery of the clitoris
o the Minor blood supplies of the vulva
Branches from femoral artery (supply the anterior part). Superficial & deep external pudendal
arteries
o The lymph node of cloquet drains
The clitoris directly
o Histology of the cervix
a) Endocervix: lined by simple columnar epithelium with compound racemose glands or crypts that
are liable to chronic infection. it secretes alkaline cervical mucus
b) Muscle layer: outer longitudinal &inner circular muscle
c) Ectocervix: formed of stratified squamous epithelium covering the outer portion of the cervix.
the junction between squamous & columnar epithelium at the external os is either abrupt or it
may form a transitional zone 1-3 mm known as the transformation zone
o the uterine artery has a tortuous course
To allow increase in the size of the uterus without over stretch of the artery (no ischemia).
o hazards during clumping the angle of the vagina in hysterectomy operation
The ureter lays 1-2 cm lateral to lateral fornix so that it may be injured.
o we give Transvaginal injection of a local anaesthetic solution around the ischial
spine
As the pudendal nerve passes & we can do minor operations on the vulva &vagina and low forceps
operations in obstetrics.

4
 GYNA REVISION NMT11

o gangrene rarely occur in fallopian tube

Because it supplied by branches from uterine& ovarian arteries so gangrene is rare to occur unless
completely twisted.
o the Tubal pain referred
To the tubal points (on the lower abdominal wall ½ an inch above the midinguinal points)
o Boundaries of The ovary?
Medially by the fallopian tube, laterally by the pelvic wall, superiorly & anteriorly it is surrounded by
the small intestine & inferiorly by the ovarian fossa where the ureter & the internal iliac vessels pass
o hazards occur to ureter during dissection of parametrium in Wertheim’s operation
& irradiation
a) A vascular necrosis of ureteric wall may occur due to cutting of its blood supply
b) Ischemic necrosis of the ureter may occur due to exposure of the ureter to overdose of
irradiations in ttt of cancer cervix
o hydatid cyst of morgagni
A pea sized thin walled cyst attached to the fimbrial end of the tube from contents of the broad
ligament
o the cervix –body
Ratio is 2\1 at birth, 1\1 at puberty, &1\3 in adults.
o The cervical mucosa has 2 ridges (anterior &posterior) from which transverse
ridges radiate to form the arbor vitae uteri
o the uterus is least vascular in the midline
o The coronary arteries
Give rise to the radial arteries that penetrate the myometrium to end as the basal arteries
supplying the endometrium
o Ovary
Is the only organ in the abdomen that is not covered by peritoneum its surface is pearly white &
corrugated by the effect or the monthly ovulatory activity
o The ovary & the fallopian tubes are included in the term adnexa
o Ovarian artery arises
From the aorta at the level of L2 & passes through the infundibulopelvic ligament
o The ovary
Is insensitive except to squeezing on P.V examination it is supplied by sympathetic &
parasympathetic nerves (T10&T11) through the preaortic plexus that accompany the ovarian
vessel.

5
 GYNA REVISION NMT11

o Removal of
The ovary (ovariotomy or ovariectomy) needs the application of 6 clamps, 2 on each pedicle
(mesovarian, infundibulopelvic & ovarian ligaments) & cutting in between to free the ovary
completely &remove it.
o Interstitial part of fallopian tubes
Has no peritoneal covering & no outer longitudinal muscles

Development of female genital tract

For mcqs
o Genetic sex is determined at the moment of conception by the presence or absence of a Y
chromosome .Until week 6, development is the same in all fetuses, after week 6 it will guide
subsequent fetal development into either male or female.
o Sexual differentiation
Gonadal differentiation: at the 6th week of fetal life, gonads are capable of differentiating
into either testis or ovary .the indifferent gonad is formed of a cortex and medulla of
mesenchymal tissue with some primitive cells called sex cord cells .primitive germ cells
(primordial cells) migrate from the wall of the yolk sac towards the developing gonads.
Subsequent differentiation depends on the presence of sex chromosomes (however
autosomes are also important)
1. Testicular differentiation:
A gene present on the Y chromosome known as testicular differentiation factor (TDF) produces a
protein called H-Y antigen which is the single for testicular differentiation.
Testicular differentiation occurs at 7th week where sex cord cells migrate, taking with it many germ
cells, to the gondal medulla which expands on the expense of the cortex.
The germ cells will form the spermatogonia while the sex cord will form the sertoli cells both of them
will form the seminiferous tubules. This is followed on week later by Leyding cell formation from
local mesodermal differentiation.
2. Ovarian differentiation
Absence of TDF and H-Y antigen, in presence of an XX pattern, will allow for ovarian differentiation
ofthe gonads.
The cortex dominates while the medulla shrinks. Sex cord cells surround the arriving dividing germ
cells (primary oocytes) to form the primordial follicles. Oocytes not surrounded by these sex cord
cells will die (what occur in turner syndrome).
The medulla now regress into a small area containing Leyding cell like cells called hilar cells and the
whole medulla is now called the hilum
o Differentiation of internal genitalia: (discuss)

In males :
•Testicular sertoli cells secrete MÜllerian duct inhibitory factor (MDIF) that inhibits MÜllerian
development (start at 61 days and completed at 80 days fetus).

6
 GYNA REVISION NMT11
•Under the effect of testicular testosterone, the Wolffian duct develops to form the vas deferens and
the seminal vesicles, while MÜllerian (paramesonephric) ducts atrophy.
•The effect of MDIF and testosterone is local affecting the side of the secreting gonad only

In females:
•Absence of MDIF, due to absence of Sertolicells, will allow MÜllerian (paramesonephric) duct to
develop forming the Fallopian tubes, uterus, cervix and the upper 4/5 of the vagina.
•In absence testosterone, the Wolffian duct will regress and is represented in the female adult by the
Gartner’s duct.
o Differentiation of external genitalia (discuss)
 start to develop from the urogenital sinus (part of the primitive cloaca) about the 10th week of
gestation .the basic parts of the primitive (undifferentiated ) external genitalia are:
i. A medial pair of swellings called genital folds
ii. A lateral pair of swellings called genital swellings
iii. A central swelling called genital tubercle
 In the male; In the presence of androgens ,enlargement of the genital tubercle forms the penis
and the genital folds fuse to become the penile part of the male urethra .the genital swellings
enlarge ,fuse and form the scrotum .
 In the female; In absence of androgens, the genital tubercle enlarges only slightly and becomes
the clitoris. the genital folds become the labia minora and the genital swellings enlarge to become
the labia majora.
o the factors needed for normal sexual differentiation
i. Normal sex chromosomal pattern
ii. Properly functioning tests producing androgens for male development. In the female ovarian
function is not needed for sexual differentiation.
iii. Responsive male end organs for testicular testosterone
o Development anomalies of fallopian tubes & their effect
a) Aplasia : This will be associated with absence of the uterus and upper 3/4ths of the vagina
b) Hypoplasia: the tube is thin, and tortuous. It may lead to infertility or ectopic pregnancy.
c) Accesory ostium
d) Tubal diverticulum :- may lead to ectopic pregnancy
o Mullerian agensis(Rokitansky syndrome)
Is a condition where there is absence of tubes, Uterus (or may be hypoplastic) and upper ¾ of
vagina, it accounts for 20 % of cases of primary amenorrhea. It is associated with normal 2ry sex
characters and may be associated with renal anomalies

The menstrual cycle

Exam questions
1-The physiology of the menstrual cycle (Sep 93)
2-The menarche (Sep 91)
Important Q & A

7
 GYNA REVISION NMT11

o hormones secreted by hypothalamus

1-GnRh 2-Corticotrophin-releasing hormone (CRH) 3-Growth hormone-releasing hormone
(GHRH) 4-Thyrotropin-releasing hormone (TRH) 5-Prolactin release-inhibting factor (PIF)
o levels of feedback to the hypothalamus
a) The long feedback loop, composed of endocrine input from circulating hormones e.g. Estrogens
b) The short feedback loop, from the pituitary hormones.
c) The ultra-short feedback loop, from the hypothalamic secretions
o control of steroidogenesis
Some autocrine & paracrine mediators, other than pituitary FSH & LH, & ovarian estrogens
&androgens play an important role in the process of folliculogenesis as:
a) Inhibin : apeptide produced by granulose cells .It attenuates FSH production and enhances
LH induces androgen synthesis ,thus the dominant follicle can continue development and
other follicles undergo atresia
b) Activin: a peptide produced by granulose cells and the pituitary gland. Its action is almost
directly opposite to that of inhibin i.e. augments FSH production.
c) Growth factors: As insulin like growth factor (IGF), fibroblast growth factor (FGF) and
epidermal growth factor (EGF), may all help enhanced responsiveness to FSH
o characters of the dorminant follicle
a) Has the most efficient aromatse activity
b) Has the highest concentration of FSH induced LH receptors
c) the greatest amounts of E2 and inhibin produced
And thus requiring the least FSH/LH levels to complete maturation
o hormonal change in different phases
Estrogens Follicular Starting low then one week before ovulation, levels of E2
phase begin to increase, at first slowly, then rapidly, reaching a
peak one day before the LH surge. After this peak and
before ovulation there is a precipitous fall .
Luteal phase E2 rises to a maximum 5-7 days after ovulation and return to
baseline shortly before menstruation
Feedback Low levels of estrogen have an inhibiting effect on LH
(negative feedback),whereas high levels stimulate LH
production (positive feedback)
Progesterone Follicular During this phase the ovary secrets only very small amounts
phase of progesterone (PRG) & 17-OH progesterone .the bulk of
progesterone comes from the peripheral conversion of
adrenal pregnolone.
Just before ovulation, the unruptured luteinizing graafian

8
 GYNA REVISION NMT11

follicle begins to produce increasing amounts of

progesterone. The elevation of basal body temperature, that
occurs after ovulation is related to the central effect of
progesterone
Luteal phase Secretion of progesterone by the corpus luteum reaches a
maximum 5-7 days after ovulation and returns to baseline
shortly before menstruation due to death of corpus luteum
.should pregnancy occur, progesterone levels, and
consequently BBT ,remain elevated
Feedback Low levels of progesterone have a positive feedback on
pituitary FSH and LH secretion. such levels of progesterone
,such as those seen in the Luteal phase ,inhibit LH & FSH
Gonadotrophins Follicular Decreasing levels of estradiol and progesterone from the
phase regressing corpus luteum of the preceding cycle initiate a
rise of FSH by a negative feedback mechanism. as estradiol
levels rise, later in the follicular phase ,there is a positive
feedback on the release of stored gonadotropins resulting in
the LH surge & ovulation .
Luteal phase Both FSH & LH are significantly suppressed through the
negative feedback of elevated serum estradiol and
progesterone levels. This inhibition until E2 & PRG levels
decline near the end of the Luteal phase due to regression of
the CL, should pregnancy fail to occur. The net effect is a rise
in serum FSH, which initiates follicular growth for the next
cycle.

o Women have around 400 cycles, last for 3-7 days, recurs every 24-32 days, about 30-50 ml/cycle
o hypophyseal-pituitary portal system
Represents a major avenue of transport for hypothalamic secretions to the anterior pituitary.

Menopause, amenorrhea & disorders of menstrual cycle

Exam questions

Cryptomenorrhea (june 2001)

Pituitary gland as a cause of amenorrhea(sep 92)

Amenorrhea due to disorders of the ovary(sep 94)

Etiology of secondary amenorrhea(sep 95)

Discuss the investigations of a case of primary amenorrhea(feb 97)

Menopausal symptoms(sep 96)

9
 GYNA REVISION NMT11

Prolactin(sep 98)

Causes and effects of hyperprolactinemia in females(sep 94)
Important Q & A
o menopause
Permanent cessation of menstruation due to intrinsic ovarian failure resulting in follicular inactivity.
o in a case of bleeding occurs during the climacteric period
Endometrial carcinoma should be excluded before attributing it to hormonal changes.
o the drugs that are used in the hormone replacement therapy
Oestrogen:
1. Estradiol valerate 1-2 mgm/day
2. Conjugated equine oestrogen 0.625 mgm/day
Progestagens:
• Testosterone derivatives:
1. Norgestrel 0.05 mgm/day
2. Norethisterone acetate 1 mgm/day
3. fGestodine 50mcg/day
• Progesterone derivatives :
1. Micronized progesterone 200 mgm/day
2. Medroxyprogesterone acetate 2.5 mgm/day
o the regimens in hormone replacement therapy
1. Sequential regimen: oestrogen alone for 2 weeks followed by a combination of oestrogen and
progestagens for another 2 weeks. Withdrawal bleeding occurs in 80% of cases.
2. Combined regimen: daily continous combination of oestrogen and progestagens resulting in less
bloating, weight gain and mastalgia. Withdrawal bleeding occurs in 20% of cases in the first year.
Oestrogen alone: used only in hysterectomized women. After hysterectomy, oestrogen is better
given alone to avoid the effects of progesterone on the cardiovascular system LDL)
o the indications for hormone replacement therapy
1. Symptomatic menopausal women to relieve menopausal symptoms
2. Premature or induced menopause
3. To prevent osteoporosis for a minority of women with one or more risk factors. Beneficial effect
occurs only during treatment and stops with cessation of treatment.
o the therapy for prevention and treatment of osteoporosis
1. Calcium supplements (1200mg/day) , vitamin D and exercise
2. HRT : for no more than 5 years , when stopped bone loss increases
3. Raloxifene (SERM): 60mg/day has a combined oestrogen-like effect (on bone) and
antioestrogenic-effect (on breast and uterus). can be used for osteoporosis if HRT is contraindicated
or refused
4. Bisphosphonates: eg; aldendronate 5-10 mg, risedronate (5 mg). it inhibits bone resorption
5. Calcitonin: nasal spray 200 mg/day. it inhibits bone resorption by decreasing osteoclasts activity

10
 GYNA REVISION NMT11
6. Phytoestrogens: plant substances found in food similar in its action to oestrogen eg; soya.
o mullerian agenesis
Uterovaginal agenesis (as Mayer-Rokitansky-Kuster-Hauser syndrome) is the second most common
cause of primary amenorrhea accounting for about 20% of cases with an incidence around 1:4000 46XX
female births. It is characterized by agenesis or partial agenesis of the mullerian structures (fallopian
tubes, uterus and upper third of the vagina).
There is normally functioning ovaries and normal cyclic pituitary –gonadal function, including ovulatory
cycles with normal secondary sexual characters. Associated renal and skeletal abnormalities are not
uncommon
o the aetiology of amenorrhoea

Aetiology of
amenorrhea

Disorders of outflow tract miscellaneous disorders

= UTERINE CAUSES
Ovarian disorders anterior pituitary disorders hypothalamic and CNS disorders

o the only uterine cause of secondary amenorrhea

Asherman’s syndrome
o Asherman’s syndrome diagnosis
The diagnosis is suggested by the absence of a normal uterine stripe on pelvic US and may be confirmed
by the absence of withdrawal bleeding after administration of oestrogen and then progestin for several
weeks. The presence of asherman syndrome can be verified by hysterosalpingography (HSG) or
hysteroscopic evaluation of the endometrium.
o the cause of ovarian failure
Due to exhaustion or depletion of oocytes.
o the causes of premature ovarian failure
1. Idiopathic
2. Karyotypic abnormalities
3. Induced by radiation therapy or chemotherapy
o hyperprolactinemia cause amenorrhoea
By suppressing hypothalamic GnRH secretion, leading to low gonadotropin and E2 concentrations.

11
 GYNA REVISION NMT11

o empty sella syndrome

Empty sella refers to an enlarged sella turcica that is not entirely filled with pituitary tissue. It is divided
into two types:
Primary empty sella: a defect in the diaphragma sella is thought to allow CSF pressure to press on the
pituitary. This type of empty sella is not associated with hypopituitarism or any other hormonal
syndrome.
Secondary empty sella: a mass enlarges the sella, but then is removed by surgery, radiation or infarction
leaving an empty sella. In this type of empty sella, hypopituitarism and amenorrhea can result from the
adenoma itself or its treatment.
o the types of hypothalamic amenorrhoea
1. Functional
2. Non-functional:
a. Infiltrative lesion
b. Congenital GnRH deficiency- Kallmann’s syndrome
o functional hypothalamic amenorrhoea
Decrease in GnRH pulse frequency and amplitude.
• Exercise: a minimum of 17% body fat by weight is required for initiation of menarche and around 20%
is required to maintain menses.
• Weight loss: considerable weight loss to or below 15-20% of ideal body weight is often associated
with menstrual disturbance or amenorrhea.
• Drug-induced: progestins (depot-provera), danazol, GnRH agonists stimulate prolactin secretion. In
addition to reserpine, methyldopa, opiates and barbiturates.
o the miscellaneous disorders that may cause amenorrhoea
1. Hypothyroidism : TSH is usually elevated which results in an elevated prolactin level
2. Cushing’s syndrome: increased adrenal activity leads to a hyperandrogenic state
o the lines of treatment in amenorrhoea
Pituitary macroadenomas: rarely a macroadenoma is unresponsive to medical therapy and may
require trans-sphenoidal surgery or Gamma knife
o the treatment of galactorrhoea
1. Exclude pituitary tumour (brain CT/MRI scans)
2. Exclude thyroid disease by ( TSH-T3-T4)
3. Drugs used for treatment of hyperprolactinemia in amenorrhea-galactorrhea syndromes :
• Bromoergocryptine 2 mg ( 1-2 tablets daily , until restoration of normal levels )
• Lisuride hydrogen maleate 0.2 mg (1-2 tablets daily , until restoration of normal levels)
• Cabergoline 0.5 mg (1/2 tablet twice weekly for 4 weeks)
o dysmenorrhoea
Painful menstrual flow. Considered the commonest menstrual complaint affecting almost 45-90% of
women in their reproductive age.

12
 GYNA REVISION NMT11

Abnormal uterine bleeding, disorders of ovulation & PCOs

Exam questions

Discuss DUB(june 99,feb 04)

Pathology of the uterus in metropathia haemorrhagica(sep 90)

Metropathia haemorrhagica(R 05)

Non-surgical ttt of DUB(june 02)

Causes of post-menopausal bleeding(feb 99,may 04, R 05)

Spasmodic dysmenorrheal(june 99)

Discuss shortly different types of DUB and give short account on metropathia
haemorrhagica(june 05)

TTT of 1ry dysmenorrheal(sep 01)

Discuess the premenstrual tension syndrome(june 98 )

Clinical types of dysmenorrheal (june 05)
Important Q & A
o the normal female age in menarche & menopause
• Menarche : 11- 14 years
• Menopause : 41- 52 years
o the causes of short cycle
• Short cycles due to short follicular phase
Short luteal phase
o classifications & types of DUB
Clinical classification Histopathological Etiological classification
classification
According to the type of According to the According to the
bleeding: endometrial underlying etiology:
1. Cyclic bleeding: histopathology: 1. Primary DUB:
• Dysfunctional 1. Ovular bleeding: • Bleeding due to functional
menorrhagia • Dysfunctional disturbance of the
• Dysfunctional menorrhagia mechanism of
polymenorrhagis • Dysfunctional menstruation in absence
2. Acyclic bleeding: polymenorrhagis of local gynecological
• Metropathia 2. Anovular bleeding: cause.
hemorrhagica. • Metropathia 2. Secondary DUB:
• Threshold bleeding. hemorrhagica. • General causes outside the
• Threshold bleeding. genital tract as;
hypertension

13
 GYNA REVISION NMT11

'hyperthyroidism '
&coagulation defects.
Iatrogenic cause within the
genital tract as; a
sequence of the use of
OCP or IUD.

o Diagnosis of DUB
DUB is a diagnosis made only by exclusion
a. History:
Excessive prolonged painless bleeding following a short period of amenorrhea.
b. Examination:
− The uterus is either normal or slightly symmetrically enlarged.
− One or both ovaries are may be cystic.
− No uterine or pelvic masses can be felt on bimanual examination.
c. Ultrasonography:
− The uterus is normal or slightly symmetrically enlarged in size, with the absence of
myomata, adenomyosis, or endometrial polyps.
− The endometrium shows abnormal thickness (> 14 mm due to hyperplasia).
− Associated cystic ovaries are sometimes detected.
d. Endometrial biopsy:
− D&C biopsy is the gold standard for diagnosis of endometrial hyperplasia.
− Simple cystic hyperplasia is the commonest finding.
− Complex (adenomatous) hyperplasia and complex hyperplasia with atypia are
premalignant conditions.
o Medical ttt DUB
• Non hormonal therapy:
a. Antiprostaglandins: e.g. mefenamic acid 250 – 500 mg t.d.s
It acts by inhibiting PG action which is increased in cases of menorrhagia
b. Antifibrinolytic agents: e.g. trenaxamic acid it acts by inhibiting the fibrinolysis in the
endometrium.
• Hormonal therapy:
o Progesterone:
o Cyclic compound estrogen/progesterone :as OCPs
o Progesterone releasing IUD:
− Highly effective may reduce blood loss by almost 95% in cases of menorrhagia.

14
 GYNA REVISION NMT11
− The continuous exposure of the endometrium to progesterone induces progressive
endometrial atrophy making it useful especially in cases requesting contraception as
well.
o ttt of postmenopausal bleeding
• Ttt of the underlying cause: HTN, bleeding disorders, HRT, senile vaginitis, vaginal ulcers &
neglected pessaries …etc.
• Any type of endometrial hyperplasia in the menopause is better treated by hysterectomy rather
than medical or hormonal ttt that may be indicated in younger age groups
• Appropriate surgical or radiotherapy ttt for malignancies
o menorrhagia
It describes bleeding in excess of 80ml / cycle. This is commonly associated with an increase in the
duration of bleeding which is normally 3-7 days (mean 5 days)
o the complaint of patient with menorrhagia
The patient will complain from prolonged menstrual flow with passage of blood clots &change of
too many diapers soaked with blood through out each cycle.
o evaluate a case with abnormal uterine bleeding
A. History:
• timing and amount of bleeding and its relation to menstruation
• previous menstrual history
• associated symptoms as

dysmenorrheal

pelvic congestion

and bleeding from other orifices
• Finally family history of bleeding disorders should be considered.
B. Clinical examination:
Bimanual vaginal and speculum examination to exclude vaginal, cervical and uterine causes
of bleeding as: adnexal masses, fibroids, adenomyosis and cancer.
C. Pelvic Ultrasonography:
TAS or TVS are excellent tools in evaluation of abnormal uterine bleeding.
Evaluation of uterine myomata, adenomyosis, endometrial polipii, suspicion for
endometrial hyperplasia, adnexal and tuboovarian masses, and associated pelvic pathology
as ascites or pelvic masses. Sonohysterography is beneficial in diagnosing endometrial
polipii.
D. Pap smear: is used to screen for cervical cancer.
E. Endometrial biopsy:

15
 GYNA REVISION NMT11
Is the gold standard in diagnosis of endometrial hyperplasia, endometrial polipii &
endometrial carcinoma.
F. Hysteroscopy: whenever an endometrial lesion suspected (polyp synaechae, etc )
G. Pregnancy test: to exclude pregnancy disorders whenever pregnancy is suspected.
o the commonest causes of menorrhagia
Local uterine causes including, fibroids, adenomyosis & uterine polyp are common causes for
menorrhagia. However the majority of cases are dysfunctional.
o the common cause of metrorrhagia
Metrorrhagia is mostly caused by local lesions in genital tract.
o the chemical properties of cervical mucous during ovulation
Glucose & chloride content, show cyclic changes parallel to E2 level being maximum at time of
ovulation
o the result of vaginal cytology during ovulation
Karyopiknotic index increase to reach its peak at time of ovulation.
o demonstration of corpus luteum help in diagnosis of ovulation
Laparoscopy done in the luteal phase of the cycle is an evidence of ovulation.
o LPD
Is the term applied to cycles with short intervals between ovulation and menstruation (less than 11
days) in which peak value of progesterone id either normal or more commonly decreased.
In both conditions there is inadequate endometrial stimulation.
o cases should be treats with clomiphene citrate
C.C: 50 ml / day starting from day 5 of the cycle in cases of inadequate FSH release during the luteal
phase.
o treat luteinized unruptured follicle syndrome
LUF: the condition is treated by a combination of (clomid+ HCG) (HMG+ HCG)
o bilateral wedge resection of the ovaries
Bilateral wedge resection: old procedure no more in use due to high possibility of creating post
operative adhesions resulting in tubal factor of infertility.
o Hyperinsulinaemia share in PCOS.
Hyperinsulinaemia lead to:
1. Increase sensitivity of theca cell to LH.
2. Decrease Aromatase enzyme activity.
3. Increase production of ovarian androgens
4. Decrease hepatic production of Sex Hormone Binding Globulin (SHBG) that lead
to level of circulating "free" androgens as well as free estrogen.

16
 GYNA REVISION NMT11

o sequelae of hormone disturbance in PCO

a) Hyper androgenism:
• Arrest in follicular growth Anovulation
• Stimulation of hair growth Hirsuitism
• Increased estrone levels from peripheral conversion in fatty tissues.
b) Hyper estrogenism:
• Irregular uterine bleeding
• Endometrial hyperplasia
• Endometrial carcinoma
o Genetic factors
May play an important role in the etiology of PCO since the disease may run in families particularly
in first degree relative.
o Cyclic bleeding
Is usually of the ovulatory type' while acyclic bleeding is usually of the anovulatory type.

Hirsutism, lower genital tract infections & PID

Exam questions

Investigation of hirsutism(sep 91)

vaginitis (feb 99)

Monilial vaginitis (sep 92,sep 94)

TTT of vulvo-vaginal candidiasis (sep 01)

Trichomonas vaginitis (july 95,june 00,june 01)

Diagnosis & TTT of trichomonasis(R 90)

Cervical erosion(june 02,june 04)

Bacterial vaginosis

Short account on cervicitis

Acute & chronic salpingitis(R 86)

C/P & ttt of acute salpingitis(R 86)

Diagnosis of acute salpingitis(june 99,june 02,june 03)

DD of acute salpingitis

Important Q & A
o classification of hirsutism
Mild: fine pigmented hair affecting the face (incomplete beard), chest, abdomen&perineum.
Moderate; coarse pigmented hair affecting the same areas as in mild cases.

17
 GYNA REVISION NMT11
Severe; coarse pigmented hair affecting the face (complete beard), tip of the nose, ear lobes, temporal
recession, chest, abdomen, perineum&proximal interphalangeal joints.
o Mixed ovarian and adrenal hyper gonadism
30-40% of cases of hirsutism are due to ovarian and adrenal hyper gonadism.increase adrenal
Production Of androgen leads to inhibition of follicular maturation&induction of premature atresia
and consequent increase in the production of ovarian androgen.
o Thyroid gland
Hypothyroidism due to decrease of SHBG may be associated with hirsutism
o Pituitary gland
-acromegaly due to increase production of GH
-hyperprolactinemia ;( prolactin stimulates production of DHAS by adrenal gland).
-increase production of adrenal androgen through (CASH)
o dexamethasone in TTT of hirsutism
Dexamethasone 0.5-1mg at bed time. It is indicated in cases of adrenal hyperandrogenism.plasma
cortisol level should be done frequently as the dose of dexamethasone should be high enough to
suppress androgen but not high to suppress cortisol.
o role of vulva as natural barrier

Defence mechanism against assent of infection (natural barrier)

Inherent resistant to infection-

Apocrine gland; modified sweat glands secretes an acid which is fungicidal

Apposition of labia leading to closure of introitus
o age affect the efficacy of defence mechanism
With age:
During childhood and after menopause due to oestrogen deficiency, the content of glycogen and
Doderlein bacilli is low leading to thin vaginal epithelium and absent vaginal acidity. The
endometrium is also poorly developed or atrophied and does not undergo cyclic shedding
o diagnosis of vulvovaginitis
Signs
Foul discharge, vulvitis, and vaginitis
Investigations

U.S. and/or x-ray to detect foreign body

Investigations to detect oxyuris, culture and sensitivity of discharge
o the investigations needed to diagnose senile vaginitis
Investigations

Exclude genital malignancy by Pap smear and fractional current

sensitivity of the discharge

18
 GYNA REVISION NMT11

o the incidence of trichmonas vaginalis

25-50%of cases of vaginitis
o the incubation period of trichomonas vaginalis
3-28 days
o incidence of monilia vaginitis
Over growth with c.albicansis actually the most common second cause of vaginitis.when the
delicate balance of organisms in the vagina is upset, the yeast may over grow and cause vaginitis
-lack of proper feminine hygiene, and prolonged exposure to moisture
o diagnosis of monilia vaginitis
Can be confirmed by culture or by presence of gram-positive spores and long pseudohyphae on wet
preparation microscopic examination. The vaginal PH is usually normal. In recurrent infections we
should look for anemia, thyroid disease, and diabetes and consider acquired
Immunodeficiency
o Give short account on incidence of BV?
BV is the most common cause of vaginitis symptoms among women of child bearing age. The
disease has been found in 12 to 25 percent of women in routine clinic population, 10 to 26 percent of
women in obstetrics clinics and 32 to 64%of women in clinics for STDS
o Amsel's criteria
A clinical diagnosis of BV can be made using Amsel's criteria (3 of the following)
1-the typical thin homogenous discharge on examination
2-ph of discharge greater than 4, 5
3-Mixture of vaginal discharge and 10% potassium hydroxide librates an" amine-like" or "fishy"
odor.
4-clue cells in microscopy, in saline wet mount or gram stain of vaginal discharge(at least 20% of
all epithelial cells).these are epithelial cells covered with bacteria that are ,clues, to the
diagnosis.menses,semen,and infection with T.vaginalis can also give a raised PH and positive
amine test.
5-a gram-stained vaginal smear has good sensitivity and specificity for the diagnosis of BV.
o complications of acute cervicitis
Complications:
1- Commonly turns to chronic infection due to racemose (branching) nature of the cervical gland.
2- Secondary vaginitis and spread of infection to upper genital tract, parametrium and urinary
tract.
o 1ry & 2ry healing phases
The columnar epithelium grows from the cervical canal to cover the denuded area(1ry healing)later
the stratified squamous epithelium grows under the columnar epithelium leading to blockage of the

19
 GYNA REVISION NMT11
ducts of the cervical glands and formation of retention cysts called Nabothian follicles(2ry healing
phase).exacerbation of infection leads to repetition of the whole process.

o the risk factors for PID

1-Sexually active females (85%): the risk of acquiring any STD is directly related to the number of
sex partners. A woman with multiple sexual partners is three times more likely to have PID than a
woman with one partner.
2-Iinjured mucosal surface (15%): after procedure as IUD insertion, endometrial biopsy, curettage,
hystero-salpingiogram.
3-Ttransperitoneal spread to upper genital tract(less than1%): from appendicitis, diverticulitis, or
traumatic rupture of the viscus.
o complications of acute salpingitis
Early
1-pelvic or generalized peritonitis
2-pelvic cellulitis, thrombophlebitis
3-abcess formation: tubo-ovarian or pyosalpix
4-septicaemia & septic shock
Late
1-Infertility due to tubal damage: incidence after 1st attack of PID is 12%, this increase to 33%
after the 2nd attack and to 75% with the 3rd attack
2-chronicity, recurrent attacks
3-increased risk of ectopic pregnancy
4-pelvic adhesions: chronic pelvic pain & dyspareunia
5-intestinal adhesions with possible intestinal obstruction.

o 5% icthyol in glycrine pessaries in Chronic salpingitis

• To diminish pelvic congestion for which cases salpingostomy are indicated.
• Salpingostomy: is indicated in cases of sterility caused by hydrosalpinx of small size when there
is no history of recurrent acute exacerbations.
o Management of parametritis
1-antibiotics (broad spectrum) 2-surgical drainage if an abscess points

o Vagina Apposition of anterior and posterior walls leading to closure

Investigations

gram stain: gram –ve rods, absent lactobacilli

whiff test: addition of 10%KOH to the discharge results in fishy odor
Culture of vaginal secretions has no place in the diagnosis of BV.30-50% of women are colonized
with G vaginalis, anaerobes and mycopasmas, as apart of their normal vaginal flora
Treatment

20
 GYNA REVISION NMT11

Cephalosporins, ampicillin and tetracyclins are also effective.
o Chronic cervicitis
Symptoms
Dyspareunia due to parametrial infection.
Treatment
Antibiotics to treat associated infection.
o Acute salpingitis
Differential diagnosis
Other causes of acute abdomen.
o Parametritis
In cellulitis pain is not severe, muscle rigidity is absent as the lesion is extra peritoneal.by
examination unilateral hard swelling that pushes uterus to opposite side.

Perineal lacerations & recto vaginal fistula

for mcqs
o causes of perineal lacerations
A) Child birth trauma:
1) Large head:
• Idiopathic ; as in large for gestational age & macrosomic foetuses
• Abnormal attitude of the foetal head ; (face presentation , direct O.P. positions and
extended after coming head in breech)
2) Narrow vaginal introitus:
• Rigid perineum (elderly primigravida , or scars of previous perineal repair)
• Contracted pelvic outlet (narrow sub-pubic arch the head posteriorly lead to great
stretching of perineal muscles)
• Sever oedema of the vulva with friable easily torn tissue (as in pre-ecalmpsia)
3) Rapid delivery of the head through birth canal: ( as in precipitate labour)
4) Bad management of the 2nd stage of labour: this is by far the most important, especially
when rapid delivery of the head occurs at the beak of uterine contraction, or an instrumental
delivery is performed without proper perineal support.
B) Other causes :
• Direct external trauma; as with fall from a height or car accidents
• Defloration injuries.
o degree of the perineal tears:
a. First degree tears: involving the skin and SUPERFICIAL PERINEAL MUSCLES.

21
 GYNA REVISION NMT11
b. Second degree tears : LEAVATOR ANI is involved as well i.e. involving the whole perineal
body .but not going through the anal sphincter .both the above types are included under the
term incomplete tears .
c. Third degree tears (complete pernieal tear) : the anterior portion of THE SPHINCTER ANI is
involved .the rectal wall may be torn leading to prolapse of the rectal mucosa
o sequelae of perineal tears:
1) Postpartum hge, due to bleeding from lacerations.
2) Infection may occur in the laceration site (puerperal sepsis)
3) Patulous vaginal introitus with persistant leucorrhoea, and unsatisfactory sexual function.
4) Incomplete tears ; may predispose to genital prolapse (due to loss of pelvic floor support)
5) Complete tears may lead to incontinence to stools and flatus due to division of the sphincter ani
muscle .After sometime, some patients will learn to contract the levator muscles and can control
the passage of solid faecal matter, but remains incontinent to liquid stools and flatus.
6) Residual rectovaginal fistula
7) Dyspareunia from a tender scar in the vagina
o Preventation of perineal laceration:
1) Proper management of 2nd stage of labour .maintain flexion of head until crowing occur + slow
delivery of head in between uterine contractions.
2) Episiotomy when the perineum threatens to tear.
o Management of perineal laceration:
• Every perineal tear, however small should be repaired. Primary suture is possible if done within
the first 24 hours if the case is seen later than that, it is considered as a septic wound and left to
heal by granulation , repair in such cases is postponed until all signs of infection have disappeared
, usually 3-6 month later.
• Perineorrhaphy in cases of a recent complete tear consists of suturing the different layers
involved in the laceration in the following order:
1)the rectal wall: is sutured in 2 layers by delayed absorbable type of sutures, first continuous
then interrupted sutures not going through the mucous membrane .the sutures should
extend well above the apex of the laceration .
2) The cut ends to the anal sphincter are identified, and are sutured together.
3) The levator ani is approximated by at least three interrupted sutures.
4) The superficial perineal muscles and fascia are approximated with interrupted sutures.
5) The vaginal and skin are finally is sutured.

o After care:

22
 GYNA REVISION NMT11
1. After every micturition, or three times daily, the vulva is washed with dettol solution, dried, painted
with alcohol .this is keep the wound, dry and clean.
2. The low residue diet is contiued , as well as the intestinal antiseptic
3. Antibiotic against wound infection
4. The vaginal pack is removed after 24 hours
5. On the fifth day the patient is given 50 ml. Castor oil. Next morning when she feels the desire to
defecate, 150ml. of olive oil are introduce into the rectum using rubber catheter, never the enema
nozzle, and retained, in order to lubricate the stools .after that the patient is given paraffin oil daily to
avoid constipation.
N.B: In the evening of subsequent pregnancy, a postero-lateral episiotomy should be done before
delivery of the head to avoid recurrence of the laceration
o Management of recto-vaginal fistula
In non malignant cases, the fistula should be closed by plastic operation. Preparation of the patient
for operation as well as postoperative care is as important as meticulous operative technique.
ESSENTIALY THE PRE- AND POST MANAGEMENT IS THE SAME as has been described under
complete perineal tears.
A) Fistulas in the lower third of the vagina:
Lawson Tait's operation: consists of cutting the Remanining Bridge of tissue below the
fistula, thus converting the fistula into a complete perineal tear. The tear is now sutured in
layers, in the same manner and order described under repair of complete tears.
B) Fistulas in the middle third:
These may closed in the same manner as has already been described for dealing with vesico-
vaginal fistulae. An alternative procedure is to start the personas in perineorrhaphy for
rectocele and to extend the dissection of the recto-vaginal septum upwards above the fistula.
The hole in the rectum is then closed, and the operation continued as aperineorrhaphy.
c) Fistulas in the upper third:
High recto-vaginal fistulas are usually surrounded by dense fibrosis, and are difficult to close
vaginally. They are usually best deal with by an abdominal (trans-peritoneal) operation.
o Traumatic causes RECTO-VAGINAL FISTULA:
Other forms of trauma include impalement injuries, and the ulceration of an ill- fitting neglected pessary.
o The post-operative care
It aims at keeping the wound DRY AND CLEAN to encourage healing by primary intention.

STD, T.B., bilharziasis

Exam questions

Transmission & prevention of AIDS(sep 91)

23
 GYNA REVISION NMT11

Chlamydial infections of female genital tract

For mcqs
o STD & causative organisms:
A sexually transmitted disease (STD) is any infection acquired primarily or principally through
sexual contact or sexual intercourse .STDS are among the most common infectious diseases in
the developed countries.
The causative organisms for STD, which are harbored in the blood or body secretions, include
viruses , mycoplasmas , bacteria, fungi, spirochetes ,and minute parasites( pthirus pubis,
sarcoptes, scabiei)
Some of the organisms involved are found exclusively in the genital tract, but others exist
simultaneously in other systems.
o the diagnostic features of the Syphilis
Syphilis is a sexually transmitted infectious disease caused by bacterium terponema pallidum.
Their spiral shaped morphology and characteristic motility pattern (they spin around their
longitudinal axis in a corkscrew type manner) are important for their diagnosis via dark filed
microscopy.
o What is the route of infection Syphilis
The organisms enter the body via minute abrasions of epithelial cell lining, by penetrating mucous
membranes or via hair follicles, and then there is a rapid systemic spread via the blood &
lymphatics. The most prominent histologic features are vascular changes caused by endarteritis
and periarteritis.
o Manifestations of systemic disease during secondary syphilis
Malaise, anorexia, headache, sore throat, arthralgia, low grade fever.
o Late syphilis
Is a non contagious but highly destructive phase of syphilis which may take many years to
develop. Late benign or gummatous syphilis is the most common form of tertiary syphilis. It
develops in 15% of untreated cases within 1-10 years after infection. Gummas may be in any
organ.
o Cardiovascular syphilis
10% of untreated cases develop these 10-40 years after initial infection . The basic lesion is an
aortitis consisting on necrosis resulting from thickening and hardening of the vasa vasorum .the
elastic tissue is replaced by fibrous tissue. This is manifested by : Aortic regurgitation because of
altered aortic valve function, aneurysm because of weakened vessel walls and obstruction of the
coronary ostia.

24
 GYNA REVISION NMT11

o Neurosyphilis
In about 8% of untreated cases, relatively early within 5-35 years after primary infection, invasion
of the CNS occurs with generalized dissemination of the disease.
o The incubation period of genital warts
Weeks to months. The virus may be carried (and shed) without any visible lesions being present.
Infection is sexually acquired
o clinical presentations of genital warts
The lesion is usually asymptomatic. Any itch usually due to secondary infection. The appearance
depends on the site. They are associated with other STDs in about 25%
o causative agents for genital Herpes
Herpes infection is caused by DNA viruses of two main types:
• HSV1: (oral & cold sores) is primarily transmitted by nonvenereal routes ,particularly
following contact with infected saliva and responsible for facial and oropharyngeal infections
like herpetic gingivostmatitis and the common cold sore or fever blister.
• HSV2: (genital herpes) is usually transmitted venereally to newborn infants and is responsible
for genital herpes and neonatal infections. Also it has been linked epidemiologically with
carcinoma of the cervix
o the incubation period of genital herpes
I.P of 21 days
o HIV tests
HIV tests can be divided into 4 groups:
1. Tests for detect antibodies
2. Test to detect antigen
3. Tests to detect or monitor nucleic acid
4. Tests to provide an estimate of T-lymphocytes numbers (cell phenotyping)
Serological tests for HIV infection are highly sensitive and specific .within 2-3 months of infection,
virtually all people will develop circulating antibodies that can be detected by serological tests.
Rarely this "window phase" between infection and seroconversion may last up to 6 months
.antibody tests are divided into screening and confirmatory tests:
1. THE ELISA screening test: (EIA or ELISA), for circulating antibodies against HIV
2. The Western blot test: usually confirms a positive ELIZA screening test.
o antiretroviral therapy for HIV
Three classes of antiretroviral therapy have been described in the treatment of HIV.
1. The nucleoside analogs: These are the older of antiretroviral medications, but their use
remains crucial in the treatment of patient with HIV

25
 GYNA REVISION NMT11
2. The protease inhibitors: they act by blocking the enzyme protease , which help in
replication of new viral particles
3. The non- nucleoside reverse transcriptase inhibitors: the medications in this group bind
none competitively to the HIV reverse transcriptase enzyme, causing disruption.
The current treatment of HIV includes the initiation of at least three of the agents all
started simultaneously.

Infertility
Exam questions

Tests for the detection of ovulation (93,94)

Detection of ovulation (2002, 2004)

Diagnosis of ovulation (2005)

Treatment of anovulation (2000, 2001, 2004)

Tests of tubal potency (93, 2001)

Indications of laparoscopy in gynecology (91)

Discuss the use of laparoscopy in gynecological diagnosis (93)

Values of laparoscopy in cases of infertility (98)

Investigations of the cervical causes of infertility (89)

Discuss the investigations of a case of primary infertility (95)

Discuss the investigations of the infertile couple (97)

Assessment of tubal patency (2005)
For mcqs
o Sterility
No possibility of natural pregnancy as in case of male azoospermia, bilateral tubal occlusion,
absence of uterus or anovulation
o What is the incidence of infertility
For young couples with no adverse factors, the chance for conception per cycle is around 20%.
Approximately 60% of healthy women up to the age of 25 years conceive after 6 months of
unprotected intercourse and 85% conceive after 12 months.
The single most important factor of infertility is the age of female since as the age is 35 years old or
above the fertility is halved & decreases sharply after 37 years old. Approximately 8-10% of couples
world-wide experience some sort of infertility.
o Disorders of spermatogenesis
Disorders of spermatogenesis are: normal scrotal temperature is 1 degree lower than body
temperature , so rise in scrotal temperature affect spermatogenesis which is found in
• undescended testes

26
 GYNA REVISION NMT11
• varicocele,hot bathes
• steam baths and tight & nylon underwear
• Microdeletion of Y chromosome.
• Intake of certain drugs as psychotropic drugs, anti-epileptic-drugs, anti-hypertensive, and
antibiotics, chemotherapeutic affect spermatogenesis.
o Disorders of sperm transport
-immotile sperms are released into lumen of seminiferous tubules and travel to the ampulla of vas
deferens where they acquire motility.
a- epididymal malformation, bilateral obstruction due to inflammation as that caused by
gonorrhea and congenital absence of vas deferens.
b- Immotile cilia syndrome
c- Bilateral surgical obstruction of vas as after vasectomy or bilateral inguinal hernia.
d- Ejaculatory dysfunction as impotence, anejaculation, premature or retrograde ejaculation.
o investigations for ovarian factor:
1) Basal body temperature: done early in morning prior to getting out of bed or any physical
activity which show elevation in basal body temperature 2days post ovulation
2) Pre-menstrual endometrial biopsy: detect ovulation by prescence of secretory endometrium
with enlarged cork screw shaped gland full of secretion, large odematous stroma with leucocytic
infilteration.
3) hormonal assay: the LH peak is defined as 3times the basal level & it occur in serum 12-24 h prior
to ovulation while it occur in urine 6-12 h later than in plasma &detected by using ovu stick & ovu
quick.
4) vaginal cytology: change of maturation index in ovulatory cycles from proliferative with
index0,30,70 to secretory with index 0,70,30 (parabasal, intermediate, superficial cells),
karyopyknotic index increase to reach its peak at time of ovulation.
5) cervical mucus: spinnbarit: reach 15-20cm at time of ovulation.`
o induction of ovulation:
1) clomiphene citrate
• Indication: cases of intact hypothalamic pituitary axis & normal FSH level as in PCO, post pill
amenorrhea, luteal phase defect & adrenal hyperfunction
• Side effects: ovarian hyperstimulation(1-2)
2) HMG
3) GnRH: given as i.v. or s.c. injection in pulsatile form by repeated dose or by automatic pumb, no
hyperstimulation as GnRH produce down regulation of its own receptors.
4) LH-RH analogue: given either by daily sc injection or nasal spray, suppress production of
endogenous gonadotropin.
5) cyclofenil

27
 GYNA REVISION NMT11
Related to cc with estrogenic action, dose 400 mg/2times daily for 5days starting from 5th day
6) surgical measures
Old method no more used due to high possibility of creating post operative adhesions resulting in
a tubal factor of infertility.
o Investigations are done post menstrual
1) to exclude pregnancy
2) decreased endometrial vascularity so decrease embolic complication
3) decrease false –ve result due to blockage of tubal mucosa by growing endometrium
4) Bdecrease incidence of endometriosis.
o rubin insufflations test
The idea of this test was to assess tubal patency through injection of air or co2 into abd, Cavity using
special instruments with insufflations cannula introduced through cervical canal &uterus.the tubes
were considered patent if the injected air or co2 pass to abd.cavity at low pressure gradient
measured by apparatus& auscultated on lower abd. Cavity as a hissing sound by stethoscope. In
cases of tubal obstruction, the pressure will rise sharply on the manometer of apparatus exceeding
normal acceptable value.
The test has been abandoned as it lack accuracy &precision as it has high false –ve &+ve result, high
risk of air embolism of a large amount of air is injected against high pressure.
It is no longer used & replaced by laporoscopy, hysterosalpingography”HSG”,
hysterocontrastsonography”HYCOSY”
o vaginal factors of female infertility
The alkaline PH of semen prevents deactivation of sperm by acidity of vagina for 2hrs. The cervical
mucus being alkaline (pH 8) allow motile sperms to penetrate it where sperm remain stored for
hours or days
1) Hostile vaginal discharge due to increased acidity or vaginitis.
2) Vaginal aplasia or vaginal septum.
o the treatment of unexplained infertility
• 10-15% of infertile couples.
• Ttt plan include up to 3 cycles of clomiphene citrate with HCG & intrauterine insemination, if
unsuccessful, the next step will be superovulation with IUI by husband semen followed by IVF.
o the typical IVF-ET cycle
1) Initial consultation & test: to choose the most appropriate technique & to explain the procedure,
its side effects & success rates.
2) pituitary down regulation: using GnRH analogues to avoid spontaneous LH surge
3) ovarian stimulation: using FSH or HMG until the leading follicles reach a mean diameter of 18-
20mm

28
 GYNA REVISION NMT11
4) Ovarian trigger with HCG: oocyte collection is carried out 34 to 36 hrs. after hCG administration
5) Oocyte collection: under trans-vaginal ultrasound guidance. Once the follicular contents are
aspirated, the cumulus oocyte complex is identified under the microscope and intubated at 37oc
in culture medium.
6) Sperm preparation &insemination:
a- In conventional IVF, prepared sperms (between 100,000-200,000) are added to each oocyte in
a container 4-6 hrs. after they are collected
b- In ICSI, the sperm is injected directly into the cytoplasm of metaphase II oocyte through the
zona pellucid under the microscope
7) Fertilization & embryo cleavage: cumulus cells are removed from each oocyte 16-18 hrs. after
insemination, the oocyte are then transferred to fresh culture medium and examined for
fertilization.
8) Vembryo transfer: 2-3 days after oocyte collection.
9) luteal phase support: by administration of progesterone or low dose hCG
o the indications of ICSI & what determines the success rate
Indications:
• Tubal factor, Endometriosis, cervical factor & unexplained infertility
• Severe male factor as azospermia and severe oligoasthenospermia.
• Failed IVF, due to failure of fertilization of oocyte.
Success rates of ICSI higher than IVF &REACH 25-40% depends on:
• maternal age
• uterine &endometrial abnormalities
• pelvic pathology (endometriosis or pelvic inflammatory disease)
• technique of procedure
o complications of ART
Complications of ovarian stimulation:
• ovarian hyperstimulation syndrome
• allergic reaction to ovulation inducing agent
Complications of oocyte retrival:
• General anesthesia complication
• failure to collect oocyte
• vaginal he
• injuries to adjacent organs
• pelvic infection
Complications of assisted reproductive pregnancy:
• Spontaneous abortion

29
 GYNA REVISION NMT11
• multiple pregnancies
• ectopic & heterotopic (intra & extra-uterine) pregnancy
• Congenital malformation
o 30-40% of all infertility is due to abnormalities of male reproductive function
o Spermatogenesis is under the endocrine control by FSH "which is under –ve feed back control by
inhibin secreted by sertoli cells" & paracrine control by androgen produced by LH stimulated leyding
cells.
o Teratozoospermia: less than the reference value for morphology.
o Aspermia: no ejaculate.
o mittleschmer pain: pain in one of the iliac fossa last for 6-12 h at time of ovulation related to
rupture of mature follicle
o hysterosalpingography:
Urograffin "water soluble media" safer: no embolism-more quickly absorbed from the body, 2nd film
is taken immediately after removing cannula or after 10 min.
Contraindication:

Symptom of pelvic pain & tenderness on bimanual examination as it may be dormant
infection.

In pre menstrual period to avoid exposure of early embryo to ionizing radiation, fear of oil
embolism, false –ve result or endometriosis.
o Laporoscopy & dye intubation:
• By injection of indigocarmine
• Therapeutic intervention with laporoscopy "adhesiolysisor ovarian cystectomy"
o Ttt. of tubal factor:
it is important to determine whether ab to Chlamydia trachomatis are present in the serum by
measuring ig G to this organism as there is good correlation between prescence of tubal adhesion
&obstruction.
o Mucus produced by secretory cells of endocervix undergo pre-ovulatory changes that facilitate
sperm transport
The preovulatory rise in estrogen makes thin watery alkaline acellular cervical mucus with water
content 95-98%. Also glycoprotein forms a parallel arrangement allowing sperm to swim down
channels.
After ovulation the cervix is firm, os. Closes & mucus become thick, cellular & scanty due to rise in
progesterone.
o In cases of anti-sperm Ab
Immunotherapy & corticosteroid have been suggested.

30
 GYNA REVISION NMT11

Endometriosis
Exam questions

Discuss Endometriois (97)

Give a short account on clinical picture of Endometriosis (98)
For mcqs

o Immunologic factors & inflammation:

• Reduced immunologic clearance of viable endometrial cells from the pelvic cavity
• Subclinical peritoneal inflammation
o the genetic factor:
Genetic factor: women with first degree relative with endometriosis have agenetic predisposition of
about 7-9% to develop disorder. (Multi-factor inheritance)
o subfertility:
• In moderate or severe cases due to ovarian involvement with adhesion sausing tubal
dysfunction. It may be also due to ovulatory dysfunction, luteal phase defect (LPD), lutenized
unruptured follicles (LUF), recurrent abortion.
• The prevalence of endometriosis is not necessarily higher in infertile than fertile woman.
o the predicted results of HSG in a case of endometriosis
Filling defect "hypertrophic or polypoid endometrium" in HSG.
o prognosis of endometriosis
Progressive in 30%-60% of patient although may improve or become eliminated.the prognosis is
variable durin pregnancy, enlarge during the 1st trimester & regress thereafter.
o the rule of (progesterone antagonist, gestrinone) as a medical treatment of
Endometriosis
• Progesterone antagonist "mifepristone 25-100mg/d": suppress endometriosis by their
antiproliferative effect on the endometrium without the risk of hypoestrogenism or bone loss of
GnRH treatment.
• Gestrinone "1.25-2.5 mg twice weekly": Have androgenic, antiprogesteronic, antiestrogenic &
antigonadotropic properties. It acts centrally & peripherally increasing free testosterone, and
decreasing SHBG. It is as effective as GnRH, with fewer side effects.
o the Indications of surgical treatment:
1) failure of medical treatment to control symptoms
2) prescence of large endometriomas
3) prescence of dense adhesions particularly in patients complaining of infertility

31
 GYNA REVISION NMT11

o Radiotherapy
Using external irradiation to destroy the ovary &induce artificial menopause is rarely restorted only
in patient >40 y with extensive adhesion &high surgical risk
o Recurrence
Tend to recur 5-20% unless definitive surgery is performed. The recurrence rate increases with stage
of disease, duration of follow-up, and the occurrence of previous surgery.
o Fertility management
Depend on the patient age, duration of infertility, stage of endometriosis. IVF is the recommended
choice.
o pathology in adenomyosis
 Localized
Similar to leiomyoma having the white whorled appearance without pseudo capsule
 Diffuse
The myometrium thickening is diffuse & of uniform consistency. The fundus is the site of
adenomyosis. It may involve either or both uterine walls, creating a globular enlargement
usually 10-12 cm in diameter.
o the differential diagnosis in a case of adenomyosis
From other cause causing symmetrical enlargement of uterus
1) pregnancy & its complications
2) submucus myoma may be present in 50% of cases of adenomyosis, the uterus is firm & not
tender, even during menstruation & dysmenorrheal occurs if the myoma is pedunculated and
in the process of expulsion.
3) carcinoma
4) Pelvic congestion syndrome "taylor's syndrome" causing continuous pelvic pain and
menometrorrhagia.
o the complications of adenomysis
1) chronic severe anemia from he
2) 1ry adenocarcinoma is rare
3) when only the endometrial stromal component invade the myometrium, the resulting tumor is
refered to as endolyphatic stromal myosis "stromatosis"
o Pathology of endometriosis:Tiny superficial hemorrhagic implants dark red or bleak "powder
burn" with adhesion formation
o The smere presence of stromal cells, in absence of glandular element of endometrium is an
enough histopathologic evidence to diagnose endometriosis
o In many patients, no abnormality is detected
Otherwise, possible signs include:

32
 GYNA REVISION NMT11
1) uterosacral or cul-de-sac nodularity
2) lateral cervical displacement
3) painful swelling of rectovaginal septum
4) ovarian cystic enlargement
5) In advanced cases, fixed retroversion with restricted motility.

Prolapse
Exam questions

Discuss the etiology of vaginal & uterine prolapse (92)

Give a short account on degrees of uterine prolapse (99)

Discuss diagnosis & treatment of geneital prolpase (93)

Discuss prolapse & its treatment (95/2003)

Causes of genital prolapse (2005)
For mcqs
o Combined recto-vaginal examination
I.e. with the middle finger in the rectum and the index in the vagina, ask the patient to contract her
pelvis as if trying to hold urine & stool. Feel every part of the pubococcygeus as it contracts and
notic its tone and whether there is a defective segment or a deep furrow in between its intact
fibers.
o Urethral diverticulum
Rare condition arising from the floor of the urethra. Pressure on the diverticulum will lead to
discharge of urine or pus from the external meatus. WE & lateral urethrographyduring voiding are
conclusive.
o the factors determines the way of ttt in genital prolapse
The choice of treatment for genital prolapse depends on several factors including the type and
degree of the prolapse, the patient's acceptance for surgical approach and her desire to preserve
coital function, and her level of fitness for a surgical approach. In general, surgical treatment is the
only curative approach for moderate and severe cases, other options are only temporary.
A) Surgical treatment:
Surgery is the only curative approach in the management of genital prolapse, aiming at
restoring both anatomy and function.
B) Pessary treatment:
Ttt is meant for temporary rather than permanent use, to bring out relief of symptoms in
cases were surgery is generally refused, risky, or should be temporarily delayed.
o pessary treatment of genital prolapse

33
 GYNA REVISION NMT11
Pessary treatment is meant for temporary rather than permanent use, to bring out relief of
symptoms in cases were surgery is generally refused, risky, or should be temporarily delayed.
Indications:
1) Slight degrees of prolapse in young patients. Operation should be postponed until the woman
has had a sufficient number of children as long as the symptoms are mild.
2) Prolapse of the uterus with early pregnancy. The pessary is worn until the end of the 4th month
when the size of the uterus will be sufficient to prevent its descent.
3) Temporary contraindication to operation as lactation, sever cough, or patients refusing
surgical repair.
4) Bad surgical risks as old patient with advanced diabetes or sever hypertension
5) To promote healing of decubital ulcers prior to surgery.
6) Therapeutic test to see if symptoms are due to prolapse.
Types of Pessaries used in prolapse:
Silicon-rubber-bases pessaries are the most popular form of conservative therapy. They are
inserted into the vagina in a similar way to the use of vaginal contraceptive diaphragms, and need
replacements at variable intervals according to the type used & the patient's condition.
I. Ring pessary: a pessary of suitable size is introduced to the vagina, above the level of the
levator ani muscles. It stretches the redundant vaginal walls and prevents descent of the
uterus.
II. Shelf pessary: rarely used (Gill horn pessary), but may be usefull in women who cannot retain
a ring pessary due to a very weak pelvic floor muscles, especially those with 2nd degree
prolapse, old age and high risk for surgical treatment.
III. Cup & Steam pessary: is no more in use nowadays.
Precautions during the use of pessary treatment:
Pessaries are considered foreign bodies in the vagina, and if neglected they may cause leucorrhea
and pressure leading to ulceration of the vaginal wall. The patient should be instructed to have
daily vaginal douches, and monthly cleaning and reintroduction of the pessary with vagina
examined for any signs of presuure or ulceration.
o Version: is the angel between the longitudinal axis of the cervix & that of the vagina. Normal
anteversion is maintained by intra-abdominal pressure.
o Flexion: is the angel between the longitudinal axis of the uterine body & that of the cervix. Normal
anteflexion is maintained by the tone of the uterine muscle.
o Anteversion: the uterus is almost at right angel with the vagina, with a slight forward curve.
o Anteflexion: the body of the uterus is bent forwards upon the axis of the cervix.
The uterus is normally anteverted anteflexed by the action of:
The uterosacral ligaments which pull the cervix posteriorly towards the sacrum.
The round ligaments which pull the fundus forwards anteriorly.
o Retroversion: the longitudinal axis of the uterus is directed backwards.

34
 GYNA REVISION NMT11

o Retroflexion: the body of the uterus is curved backwards upon the axis of the cervix.
Retroversion and Retroflexion usually occur together (retroversion flexion R.V.F.)
o Signs of R.V.F. (Retroversion Flexion of the uterus)
1) Digital vaginal examination:

The external os of the cervix instead of pointing downwards & backwards the sacrum is felt
pointing upwards & forwards towards the symphysis pubis.
2) Bimanual examination:

The body of the uterus is through the posterior fornix.

Determine the mobility of the uterus.
3) Sounding: If a uterine sound is passed gently, it goes downward & backwards.
o the Treatment of R.V.F.:
1) No symptoms: the majority of cases is congenital, asymptomatic, and requires no treatment.
2) Symptomatic cases: usually secondary to the pre-existing pathology as; endometriosis, chronic
PID and cervical erosions. Treated according to the management of the primary case.
a) Surgical treatment: the same
b) Prophylactic measures against RVF include:
• During purperium: early ambulation, regular pelvic floor exercise and bladder
evacuation.
• During abdominal myomectomy: placation of round ligaments after removal of large
myomata to keep the fundus anteriorly.
• During operations for uterine prolapse: shortening of Mackenrodt's ligaments infront
of the cervix anteriorly, or uterosacral ligaments posteriorly will restore the normal AVF
position of the uterus.

Pessary test: the uterus is corrected, and a Hodge Smith pessary is inserted to keep the
uterus in the corrected position. The patient is re-examined after one month, if her
symptoms were relieved, this means that symptoms were due to retroversion.

Pessary Treatment: in cases of mobile RVF, the plastic Hodge Smith pessary is introduced
to stretch the uterosacral ligaments by its posterior causing shortening of the ligaments
pulling the cervix posteriorly. Since the uterus should be corrected bimanually to become
anteverted before introducing of the pessary, therefore pessaries are of no use in fixed
retroversion.
o Chronic Inversion of the Uterus
It is a condition in which the uterus is partially or completely turned inside out.
Etiology & Types:
1) Acute inversion: this is the more commonly seen type, although generally rare,
Mostly occurring as a complication of 3rd stage of labour due to forcible traction on the
placenta.

35
 GYNA REVISION NMT11
N.B. for acute inversion of the uterus, see obstetrics complications of 3rd stage labour.
2) Chronic inversion: this is even more rare occurring mostly;

As a sequel of neglected or overlocked acute inversion

Secondary to dragging of the uterine fundus by a submucous fundal myoma, or
sarcoma.
Degrees of chronic inversion:
1st degree: A depression of the fundus, which does not reach the cervical canal.
2nd degree: The inverted fundus passes through the cervix and appears in the vagina.
3rd degree: The whole inverted uterus reached the introitus
4th degree: The whole uterus & vagina are completely everted outside the interoitus.
Symptoms:

Vaginal discharge: due to chronic endometritis.

Irregular uterine bleeding: due to endometrial ulceration.

Pain & Dysparunia: due to the presence of ovaries in the uterine cup.

A mass felt in the vagina.
Signs:

P.V.: A mass felt in the vagina.

Bimanual examination: A characteristic cupping is felt by the abdominal hand. The vaginal
hand can detect an opened cervix with the inverted fundus protrouding.

Speculum: A red mass is seen in the vagina resembling a fibroid polyp.

Sounding: Sound will not pass in 3rd degree inversion; a short uterine cavity is found in 1st &
2nd degrees.
Differential Diagnosis:
1) A fibroid polyp protruding through the cervix. Here the uterus is felt normally
bimanually (no cupping), there is an external os and a uterine sound can be introduced normally.
2) A mass protruding in the vagina e.g. uterine prolapse or sarcoma or a cauliflower
cancer cervix. Differentiated by the presence of the cervix; bimanual examination & sounding.
Treament:
• Chronic puerperal inversion:
1. Clear up infection: by keeping the patient flat in bed and by antiseptic packing.
2. Surgical correction of chronic inversion; (indicated in young patients):

Abdominal approach: Haultian's operation; in which a posterior incison is made in the
cervical ring and upper vagina, releasing the fundus and correcting the inversion by
upward fundal traction that could be associated by a vaginal hand.

Vagianl approach: Spinelli's or Kustner's operation; are more difficult and rarely done.
3. Surgical Removal of the uterus by Hysterectomy: is indicated in postmenopausal
women. Either a total abdominal or a vaginal hysterectomy may be performed.

36
 GYNA REVISION NMT11
• Inversion due to fundal tumour:

Young patients: Vaginal Myomectomy, correction of the inversion.

Old patients: Abdominal or vaginal Hysterectomy.

In malignant tumours: treatment according to the condition.

Urology
Exam questions

Aetiology of vesico-vaginal fistula (feb 04)

Causes of vesicovaginal fistula (R 00)

Differentiation between vesicovaginal & ureterovaginal fistula (may 2000)

Causes &diagnosis of ureterovaginal fistula (june 04 ,R 00)
Important Q & A
o anatomy of the bladder, urethra, urethral sphincter
The bladder
• Is a hollow muscular organ normally situated behind the symphysis pubis.
• It`s composed of a syncytium of smooth muscle fibers know as the Detrusor muscle.
• It`s covered superiorly & anteriorly by peritoneum & is connevted to the proximal urethra at
the bladder neck which rest on the urogenital diaphragm.
• The detrusor muscle has a rich cholinergic parasympathetic supply(S2,3,4)
• Contraction of this meshwork of fibers results in stimulation reduction of the bladder in all its
diameters.
The urethra
• Is a thin-walled muscular tube that drains urine from the bladder to outside the body
• The epithelium of the urethra is transitional near the bladder, stratified epithelium near the
external opening & pseudostratified columnar epithelium in between.
• Beneath this thick epithelium is a rich vascular plexus which contribute up 1/3 the urethral
pressure.
• The urethra has minimal parasympathetic innervations & its smooth muscles are innervated by
sympathetic fibers (t10, 11, 12).
• Stimulation of these sympathetic fibers produces uretheral contraction via α-adrenergic
receptors. Β-adrenergic receptors produce uretheral & detrusor muscle relaxation.
Urethral sphincters
The internal urethral sphincter (involuntary): At the bladder-urethral junction, a thickening of the
detrusor muscle forms
The external urethral sphincter (voluntary): is skeletal muscle & surrounds the urethra as it
passes through the urogenital diaphragm.

37
 GYNA REVISION NMT11

o the physiology of micturation

As urine accumulates, the bladder stretches & stretch receptors are activated. This cause a reflex
that result in relaxation of the detrusor muscle & contraction of the external urethral sphincter.
When about 200 ml. of urine has accumulated, impulses are sending to the brain & one begins to
feel the urge to urinate.
Activation of the micturition centre in the pons signals parasympathetic neurons that stimulate
contraction of the detrusor & relaxation of the sphincter.
During micturition:
1. Relaxation of pelvic striated muscle (pudendal nerve inhibition).
2. Relaxation of the Fascial support ( parasympathetic effect) lead to:
• Desent of bladder neck
• Funneling of the urethra
• Increase of the urethra-vesical angle 180
• Increase of urethral pubic angle 45
3. Contraction of detrusor muscle (parasympathetic effect).
o Urinary incontinence
Urinary incontinence is the involuntary loss of urine that is objectively demonstrable & result in
social hygienic problem.
o the Incidence
Increase with Age & parity:
5% for< 45 10% for age between 45 and 50 30% for > 65
o the classification
A) Extraurethral incontinence: fistula (vasicovaginal, uretovaginal , urethrovaginal)
B) Urethral incontinence:
1. Urodynamic stress incontinence (USI), also called genuine stress incontinence (GSI)
2. Detrusor overactifity (DO), also called detrusor instability (DI), or (urgency incontinence).
3. Mixed type(commonest)
4. Overflow incontinence (retention with overflow).
o Common symptoms associated with incontinence
1. Urgency: a sudden desire to void.
2. Frequency : urination 7 or more times a day or working more than once at night to void
3. Stress incontinence: loss of urine on physical effort. It`s not a diagnosis
o urodynamic stress incontinence (USI)(Genuine stress incontinence)
Stress incontinence means loss of urine on physical effort. It`s a symptom & a sign but isn`t a
diagnosis.

38
 GYNA REVISION NMT11
• USI is the involuntary loss of the urine, through the urethra, during increased intra-abdominal
pressure (IAP), in absence of detrusor muscle.
• This is will occur only when the intravesical pressure exceeds the maximum urethral closure
pressure due to weak urethral sphincter mechanism.
• USI is the commonest cause for female urinary incontinence & urethral hypermobility following
child birth is most common cause of USI.
o the pathophysiology of USI
• The bladder neck & proximal urethra are normally situated in an intraabdominal position above
the pelvic floor & are supported by the pubourethral ligaments; this position allows increase in
IAP to be transmitted equally to the bladder & proximal urethra maintaining urethral closure &
continence.
• Damage to either the pelvic floor musculature (levator ani) or pubourethral ligaments may
result in descent of the proximal urethra & bladder neck, such that they will become no longer
intra abdominal organs. This descent prevents transmission of IAP to the proximal urethra
leading to an increase in the intravesical pressure over the intraurethral pressure during
straining with a consequent leakage of urine per urethra during stress.
• This typically occurs in women that experience loss of support in the anterior vaginal wall
leading to prolapsed & descent of bladder neck & urethra.
• Reduction in the resting urethral closure pressure occurs due to fibrosis, scarring or estrogen
deficiency, with resultant weakness of the internal urethral sphincter.

o grading of USI
1. Grade І: incontinence with severe stress.
2. Grade ІІ: incontinence with moderate stress (rapid movement. Walking up or down stairs).
3. Grade ІІІ: incontinence with mild stress (while standing).
o detruser overactivity
(Previously called detrusor instability) is a Urodynamic observation characterized by involuntary
detrusor contraction during the filling phase which may be spontaneous or provoked.
o aetiology

Local bladder irritation (e.g. infection, stone, ulcer, polyps….).

In association with over evidence of neuropathy e.g. DM, DS, spinal cord or brain lesions.

Idiopathic (most common).
o Diagnosis
The diagnosis can only be made by Urodynamic investigation tests when there is failure to inhibit
detrusor contractions during cystometry.
o overflow incontinence

39
 GYNA REVISION NMT11
Definition: insidious failure of bladder emptying that may lead to chronic urinary retention &
overflow incontinence.
Etiology

Hypotonic bladder; as in lower motor neuron disease, spinal cord injury or autonomic
neuropathy e.g. (DM)

Out flow obstruction: external or urethral (large cervical myoma)

Acute retention with overflow e.g. postoperative. Postpartum or infection.

Iatrogenic e.g. anticholinergic & anticonvulsant drugs.
Clinical presentation
A) Symptoms: patient usually present with various symptoms including dribbling of urine,
straining to avoid with poor stream. & unawareness of the urine loss
B) Physical Examination

General examination: weight gait, chronic chest disease.

Abdominal examination: abdominal mass. Hernia.

Pelvic examination: Atrophy, displacement, Weak perineal muscle.

Examination for neurologic disorder; muscle weakness, paralysis, deep tendon reflex.
o investigations for urinary incontinence
1. Midstream urine for culture & sensitivity.
2. Urodynamic tests:
These are tests which are employed to determine bladder function. They are indicated
whenever multiple symptoms are present, mixed types of incontinence suspected, or where
difficulties arise in differentiating USI from DO.
a. Cystometry: measures the pressure volume relationship within the bladder. It can detect
intravesical pressure and intraurethral pressure during rest & voiding. Cystometry can
differentiate between USI & DO in majority of case.
b. Uroflowmerty: rate of urine flow through urethra (N = 15 ml/sec)
c. Urethral pressure profile: traces intraurethral pressure along urethral length
− DO: is diagnosed if there is rise of the bladder pressure during the filling phase >15cm
H2O.
− USI: is diagnosed if leakage occurs as a result of increased intraabdominal pressure in
the absence of rise in detrusor pressure.
3. Other tests: IVP, MRI, Cystourethroscopy, Electromyography only for special cases .
o theParameters of normal bladder function
1) Residual volume<50 ml 2) First desire to void between 150-200 ml
3) Capacity (strong desire between 400-600) ml 4) detrusal pressure during filling <15 cm
H2O
5) Absence of systolic detrusor contractions 6) No leakage on cough

40
 GYNA REVISION NMT11

o Management of urodynamic stress incontinence

A) Prophylactic measures:
- Avoid prolonged 2nd stage of labour and minimize child birth trauma.
- Pelvic floor exercises especially in the puerperium, or after pelvic surgery.
- Avoid marked obesity and overweight.
- Proper treatment of chronic cough and constipation especially in the post menopausal
period.
B) General measures and exercise:
- Restrict fluid drinking to 1 liter / day.
- Weighed vaginal cones inserted in the vagina; to stimulate pelvic floor muscle contractions,
as a sort of muscle exercise.
- Maximum electrical stimulation.
C) Medical treatment:
- Oestrogen in cases of menopausal atrophy.
- Alpha sympathomimetics (phenylpropanolamine).
- Combination of both is the best.
D) surgical treatment of USI:
- Surgery is the gold standard in treatment of USI, aiming at;
- Restoration of the proximal urethra and the bladder neck by their elevation to the region of
intraabdominal pressure transmission (i.e., elevation to a retropubic position).
- Increase urethral resistance.
Operations for USI:
1- Colposuspension operations (e.g.: burch Colposuspension):
o Attachment of the upper vagina on each side to the cooper’s or the pectineal ligament at
the inferior border of the pubic arch by an abdominal approach.
o Associated with the highest success rate (95% after 1 year, & 75% after 15 years).
2- The sling procedures.
a. Autologous materials; using fascia and rectus sheath.
b. Synthetic materials (tension free vagina tape-TVT). This has an advantage of very high
success rate, up to 90%, shorter stay in the hospital as it is performed under local
anaesthesia. It is considered now by many the treatment of choice for stress incontinence.
3- Kelly’s placation with anterior colporrhaphy:
A. Indicated when repair of cystocoele is planned by anterior colporrhaphy.
b. Associated with 60-70% success rate but fall to 30% after 5 years.
c. Less morbidity than any other abdominal procedure.
4- Periurethral injection of collagen.
-this is a short term treatment, but long term results are only 30% after 5 years.

41
 GYNA REVISION NMT11
5. Needel suspension
-peyrera and stamey procedures are not used nowadays (30% cure rate after 5 years).
o the Treatment of detrusor overactivity
1. Behavioural: bladder retraining tends to increase the interval between voids and inhibit
symptoms of urgency. However it is time consuming & requires cooperative patients.
2. Medical treatment
a. Anticholinergic drugs: they reduce the vesical pressure and increase the bladder volume.
- Oxybutinine 2.5mg twice daily
-Tolterodine or detrusitol (drug of choice) as it has less side effects, 2mg twice daily.
b. Imipramine often used for enuresis and
c. Antidiuretic hormone as desmopressin often used for nocturia.
o genito urinary fistula
Abnormal communication between the urinary and genital organs. Two golden rules must be
remembered. The first rule is that: urinary escape from ureter, bladder or urethra and in case of
first 2, communication may be with tube, ureter, cervix or vagina; urethral fistulas are always
vaginal. The second rule is that, in naming a fistula, the part of the urinary tract is the first to be
described
o the mangment of vesico-vaginal fistula
Prophylaxis:
1. In the antenatal examination, abnormalities which may possibly later result in fistula
formation (as contracted pelvis and malpresentation) should be diagnosed in time & the
correct inference should be drawn.
2. During labour, the doctor should recognize & suitably deal with such causes of urologic injury
as prolonged labour, contracted pelvis and malpresentation; such must be transferred to
hospital in good time.
3. Risky operations especially the high forceps, the forceps with incompletely dilated cervix &
risky destructive operations should all be avoided.
• If the injury to the bladder is discovered during a difficult labour, it is of title use to suture the tear
due to the edema & friability of the tissues. A rubber catheter should be fixed in the urethra, and
left in for 10 days, inorder to deliver the flow of urine away from fistula. The tear may thus heal
completely, or failing this, it will be left much smaller size.
• If the injury is detected some time after labour, as in case of necrotic fistulae, operations for
closing the fistula should not be done except at least 3 months after delivery to allow for
maximum involution of tissues.
Pre-operative preparation:
1. The vulvitis often present is as infective focus, & contra indicates operation until it is cured.
This is obtained by keeping the skin of the vulva, &inner aspect of the thighs continuously

42
 GYNA REVISION NMT11
covered by a thick layer of Vaseline, zinc oxide ointment or any bland ointment, to prevent
maceration of the skin by the continuous discharge of urine. Any phosphatic deposition on the
vulva should be scraped & the ulcers resulting painted with silver nitric until healed.
2. Renal function tests, such as the urea clearance, urea concentration test, &blood urea should
be performed. Operation should be postponed if the tests show poor kidney function.
3. Culture of urine is done & if pathogenic organisms are found, the patient is given urinary
antiseptics until the urine is sterile.
4. Methylene blue test is done to differentiate a small vesico-vaginal fistula from a uretero-
vaginal fistula. Methylene blue test: three pieces of gauze are placed in the vagina one above
the other & 200 cc of sterile fluid colored with methylene blue in injected into the bladder
through a sterile rubber catheter. The catheter is removed & the patient is asked to walk about
for at least 20 minutes. The lowest piece of gauze is discarded as it is usually stained during
filling the bladder. If the middle or upper pieces stain, the fistula is vesical but if none of the
pieces stain & the upper one is wet with uncolored urine, the fistula is ureteric. If the pieces of
gauze are dry & unstained, this excludes vesical or ureteric fistula.
5. Cystoscopy is important to determine the relation of the fistula to the ureteric openings in the
bladder, and to exclude multiple fistulae. Cystoscopy can also reveal any, associated bladder
pathology. During Cystoscopy , the assistant injects 4 cc of 0.4% indigocarmine solution
intravenously. If kidney function is good, the blue efflux is seen from the ureter in 4 minutes
(chromocystoscopy)
OPERATION
І. the operation usually preformed is the flap- splitting operation, or “dedoublement”
a. Circular incision is made around the margin of the fistula. From this incision, two short
longitudinal cuts are carried upwards & downwards, going through the thickness or the
vagina but not the bladder. This results in two flaps of vaginal wall
b. The next step consists of free mobilization of the vaginal flaps from the bladder over a
wide area, at least 1½ cms around the fistula. This is a most important step.
c. The hole in the bladder is then closed by2 layers of interrupted going through the muscle
wall only, and not piercing the mucous membrane. The first layer is through & through
(from edge to edge); the 2nd layer should be of the inverting Lembert type to invert the
mucosa & make the closure water-tight.
d. The vagina is then closed by interrupted sutures going through its whole thickness
e. A rubber catheter is fixed in the urethra to avoid any distention of the bladder, which will
strain the stitches.
f. The last step is tight vaginal pack to prevent any reactionary hemorrhage.
ІІ. The saucerisation operation (or sim`s operation):

43
 GYNA REVISION NMT11
The edge of the fistula is excised removing a wider part of the vagina than of the muscle
wall of the bladder (but don`t remove any part of bladder mucosa)
& the edges of both organs are simultaneously coapted together by the use of non-
absorbable suture of silver wire or nylon. This operation is done if the tissue are so
adherent & fibrosed that impossible to do flap-splitting operation. Also indicated after
failure of the flap splitting procedure.
ІІІ. Certain high fistula are better treated by abdominal (transperitoneal or transvesical)
repair
Post-operative Care:
1. The patient is carried to her bed, where she lies in the recumbent
2. The bladder should be kept constantly empty to avoid any tension on the sutures in its
wall. This is insured by continuous observation of the urine, every two hours day & night.
3. Fluids are given in copious amounts, at least three liters per day.
4. Urinary antiseptic as well as antibiotics are given
5. The vaginal pack is removed 24hours after the operation.
6. The catheter is removed AFTER 10 DAYS, never before after it`s removel the patientis
instructed to avoid urine every two hours by day, & every four hours by night, to avoid over
distention of the bladder & disruption of the suture line.
Subsequent Management:
The patient is instructed to avoid sexual intercourse for a period 3 months (in other vaginal
operations coitus is avoided for only 1 month) & try to avoid pregnancy for at least one year
after operation. In the majority of cases vaginal delivery carries the risk of recurrence of the
fistula, & caesarean section is almost absolutely indicated.
o the kidney function tests
1. Blood urea: Normally 20-40 mg%
2. Specific gravity of urine before and after water administration ( water concentration test):
Normally high before, low after but in chronic nephritis there is low fixed S.G. of about 1010. This
is the most sensitive test.
3. Urea concentration test: Normally urea in urine’ should be 2 % or over after administration of 15
grams of urea by mouth.
4. Urea clearance test: It indicates the number of cubic centimeters of blood cleared of urea per
minute (there is a special formula for its calculation). Average clearance 70-120% below 50%
indicates renal impairment It is a delicate test .
5. Intravenous pyelography.
o types of incontinence of urine
1. True incontinence caused by genitor-urinary fistula.
2. Stress (sphincter) incontinence due to weakness of the internal urethral sphincter

44
 GYNA REVISION NMT11
3. Urgency incontinence caused by sever inflammation leading to marked irritation of the bladder
and so the urge to pass urine cannot be inhibited and some urine will pass involuntary while the
patient is in her way to W.C.
4. False incontinence (retention with overflow).
5. Nocturnal enuresis.
o The urogenital diaphragm is part of the pelvic diaphragm which is the muscular portion of the
pelvic floor that provides a stable base on which the bladder neck & proximal urethra rest.
o Acute temporary incontinence may occur with child birth, limited mobility, medication, side
effect or urinary tract infection.
o DETRUSOR OVERACTIVITY is second most common cause of female incontinence, after USI, &
accounts for 30-40% of causes.
o Associated symptoms detruser overactivity include: urgency, frequency, urgency
incontinence, nocturia, stress incontinence, voiding difficulty & dysuria.
o Dedoublement: The same principle is applied also when closing the rectum or the uterus. Position
with apillow under her knee, & the catheter is lead to a collecting bottle by a polythene tube.
o This variety of fistula nearly always occurs as a result of injury to the ureter during a gynecological
operation as hysterectomy but may also develop following a difficult labour.
o The urine from the affected ureter escapes from the vagina while the bladder fills up & empties
normally from the ureter (incomplete incontinence)
o The fistula is always small & situated high up in the vagina lateral to the cervix. It can be
differentiated from a vesico-vaginal fistula by the methylene blue test. Cystoscopy shows a normal
bladder & the presence of the ureteric efflux on one side only.
o When the ureter is likely to be injured during an operation it`s injury which may result in a ureteric
fistula, can be avoided by pre-operative intravenous pyelography & ureteric catheterization, & by
prober surgical technique
o After determining which ureter is involved, it is by abdominal re-implantation of the ureter
into the bladder. If this is not possible the affected ureter is transplanted into sigmoid colon. If likely
function is very poor on the affected side, this kidney can be sacrificed.

Non neoplastic cysts

Important Q & A
o neoplastic and non neoplastic ovarian swelling
Non neoplastic cysts Neoplastic cysts
1. Incidence Commoner Less commoner

45
 GYNA REVISION NMT11

2. Nature Always benign May be benign or malignant

3. Aetiology Functional hormone disorder Unknown
Excessive levels of HCG
Endometriosis
Inflammation
4. Examples -Follicular cysts -Serous cysts
-Corpus luteum cysts -Mucinous cysts
-Theca lutein cysts -Endometrioid cysts
- Endometriotic cysts -Dermoid cysts
- Inflammatory cysts
5. Course Usually regressive Always progressive
6. Treatment Usually conservative using; Always surgical
Medical treatment
Hormonal treatment
Rarely surgical

o types of non neoplastic cysts of the ovary

I. Follicular cysts
II. Corpus luteum cysts
III. Theca lutein cysts
IV. Endometriotic cysts
V. Germinal inclusion cysts
VI. Inflammatory cysts of the ovary
o follicular cysts
Follicular cysts are the commonest non neoplastic cysts of the ovary. They may arise either
from cysts over-distension of an atretic follicle, or a dominant Graafian follicle that failed to
rupture.
Spontaneous regression and resolution within a few weeks is almost always the rule, unless they
are complicated by hemorrhage, or rupture.
Pathology:
Cysts are usually single, unilateral, small in size (<7cm), unilocular, containing clear fluid. the cyst
wall is thin, lined by granulose cells that may continue to produce oestrogen causing menstrual
disturbance. Follicular cysts of the ovary are commonly encountered with;
a) Metropathia Hemorrhagic (MH).
b) Polycystic ovarian syndrome (PCOS).
c) In association with fibroids and endometriosis.

46
 GYNA REVISION NMT11
Fate & complications: spontaneous resolution is the rule. Rarely hemorrhage may occur
(producing follicular hematoma), or the cysts may rupture spontaneously if large and rapidly
growing producing pain with a picture simulating acute abdomen.
Clinical picture:
- Asymptomatic; follicular cysts are usually asymptomatic.
- Menstrual disturbance; delayed menstruation or irregular bleeding due to persistent
oestrogen production leading to endometrial hyperplasia (see abnormal uterine bleeding).
Pain (rarely acute abdomen): If the cyst is large, rapidly growing, or ruptures. It may cause
pain in one of the iliac fosse that may simulate that of appendicitis.
Diagnosis:
- Abdominal palpation may or not reveal tenderness at the ovarian point (above the mid
inguinal point), or at one of the iliac fosse.
- Bimanual examination may reveal fullness and tenderness on one of the adnexal. The cyst
may rupture during pelvic examination.
- Ultrasonography: pelvic TAS or TVS, is the gold standard in diagnosis, showing single,
small, unilocular, echolucent, thin walled cysts with no septations or internal echoes.
D.D.: from simple serous cystadenoma which is a benign ovarian neoplasm, lined by low
columnar or cuboidal epithelium. Associated pain should be differentiated from other causes of
pain in either iliac fossa (appendicitis, ureteric stones …ect).
Treatment:
A) Conservative by follow up and repeat US: unit complete resolution of the cyst. A decrease in
the size of a cyst on repeated US scan is an indication of its functional nature. During follow
up hormone therapy by gestagens or combined oral contraceptive pills (OCPs) may
accelerate resolution of functional cysts.
B) Surgery (ovarian cystectomy): is rarely indicated except if the cyst ruptures causing acute
abdominal pain with intraperitoneal hemorrhage, or if the cyst is persistent (or increasing in
size), to exclude a neoplastic origin, particularly in the elderly patient. Ovarian cystectomy is
performed either by laparotomy or laparoscopy, with conservation of the ovary.
o Corpus luteum cysts
They are less common than follicular cysts, arising from excessive hemorrhage inside the corpus
luteum during the stage of vascularisation.
Pathology:
Cysts are usually unilateral, single, unilocular, small size (3-7cm), containing either bloody
fluid or clear content. The cyst wall is lined by leutinized granulose cells that may continue to
secrete progesterone causing menstrual disturbance.
Fate & complications:

Spontaneous resolution is the rule.

47
 GYNA REVISION NMT11

Hemorrhage may rarely occur (producing corpus luteum hematoma).

Spontaneous rupture in rapidly growing cyst may occur, resulting in pain simulating acute
abdomen.
Clinical picture:

Asymptomatic: the majority of corpus luteum cysts are usually asymptomatic.

Menstrual disturbance: may be present in the form of a short delay in the menstrual cycle,
due to persistent progesterone production, commonly followed by irregular vaginal
bleeding (D.D. from abortion and Metropathia hemorrhagica).

Acute lower abdominal pain may be present in one of the iliac fosse if the cyst is
complicated with hemorrhage or rupture.(DD; from ectopic pregnancy, where a B-hCG will
be positive, and acute appendicitis if on the right side, where a CBC will be suggestive)
Diagnosis: is settled by detection of the cysts by pelvic TAS, or TVS.
Differential diagnosis: same as follicular cysts
Treatment:
A) Conservative: follow up and repeat US is the rule as most cysts will regress then
disappears spontaneously. The possibility of early pregnancy should be always
considered.
B) Surgery (laparotomy, or laparoscopy); is rarely indicated if the cyst ruptures causing
acute pain with intraperitoneal hemorrhage. Cystectomy is performed with ovarian
preservation.
o Theca lutein cysts
There is becoming more common in the last decade. They commonly arise duo to ovarian
hyperstimulation by either:
a. Excessive amounts of HCG in circulation; as in Hydatidiform or choriocarcinoma (rarely
in multifetal or singleton pregnancies), or during iatrogenic use of hCG injections for
induction of ovulation in anovulatory infertility.
b. B. excessive amount of pituitary gonadotropins: as with induction of ovulation using
HMG, or Gn RH analogues or less commonly with clomiphene citrate (C.C.).
Pathology:
Cysts are usually multiple, commonly bilateral, bluish in color, thin walled, containing clear
fluid. They may reach a large size >20 cm as in the serious complication of ovarian
hyperstimulation syndrome (OHSS). Cyst wall is lined by leutinized theca cells.
Fate & complications: majority of cysts will undergo spontaneous regression whenever HCG
levels fall (after evacuation of a Hydatidiform mole, or after discontinuing exogenous HMG / Gn
RH stimulation therapy). Less commonly cysts may undergo torsion or hemorrhage, especially if
moderate to large size.

48
 GYNA REVISION NMT11
Diagnosis: pelvic Ultrasonography: multilocular, bilateral, echolucent cysts in a patient with a
history suggestive of abnormally elevated hCG levels, or ovarian stimulation by HMG/CC...
Treatment:
Expectant treatment after removal of the source of gonadotropins stimulation (e.g.;
evacuation ofa molar pregnancy or withholding ovarian stimulating drugs in OHSS).
Laparotomy should always be avoided if possible, unless cysts are complicated.
o Endometriotic cysts
Incidence & origin: Not uncommon especially with infertility and pelvic endometriosis.
Pathology: these cysts represent accumulates within the cyst duo to the menstrual reaction of
the endometrium occurring every month. By time, absorption of the serous elements of the
retained blood occurs leaving behind RBCs, which gives its contents their characteristic thick
chocolate appearance (chocolate cysts).
Endometriotic cysts have a relatively thick wall, their size is rarely large, and spontaneous
rupture is uncommon. They are surrounded by dense fibrous adhesions (due to repeated
leakage of the cyst as result of repeated hemorrhage), and therefore rarely undergo torsion.
Clinical picture and treatment: (see chocolate cyst in endometriosis)
- Superficial ovarian lesions can be vaporized.
- Small endometriomas<3 cm can be aspirated, irrigated, and the interior wall vaporized.
- Large endometriomas>3 cm require removal of the cyst wall to prevent recurrence.
o Inflammatory cysts of the ovary
Origin: these may be in the form of Tubo-ovarian cysts or Tubo-ovarian abscess. (specific or non
specific ). Infection may reach the ovary either by lymphatics or a nearby-infected organ.
Clinically: inflammatory cysts of the ovary are usually bilateral, and the patient usually presents
with a history of recent delivery or abortion, a recent surgical pelvic operation or IUD insertion.
Diagnosis and treatment: (see chronic PID, Tubo-ovarian cyst & abscess).
o Germinal inclusion cysts
They are microscopic cysts that result from invagination of the germinal epithelium into the
substance of the ovary near or after menopause. Previously they were considered of no clinical
importance, but now they are regarded as forerunners for ovarian epithelial cancers.
o Enlargement of the ovary presenting by an adnexal mass, is one of the common
gynecological conditions encountered in clinical practice. The majority of such ovarian swellings are
Non neoplastic in origin (functional cysts of the ovary), however others are neoplastic
representing either benign or malignant tumors of the ovary.
o Non-neoplastic (functional) cysts of the ovary are the commonest ovarian swellings
encountered in clinical practice.
o Cysts are mostly unilocular, thin walled, with no internal echoes or solid areas

49
 GYNA REVISION NMT11

o They are usually small in size & rarely exceed 7.0 cm in diameter
o The majority are discovered incidentally during routine pelvic examination or US
o They are sometimes associated with temporary menstrual disorder
o Their fate is generally spontaneous resolution within few weeks of diagnosis
o Surgical intervention is rarely needed, & only if complicated.

Diseases of the vulva & vagina

Important Q & A
o General medical conditions that may have vulvar manifestations :
DM, Crohn’s disease, atopic sensitivity, psoriasis or other skin diseases
o Causes of pruritus without vaginal discharge :
1. Drug sensitivity : skin sensitivity to various chemical constituents of toilet preparations such as
soaps ,bath salts & antiseptics may explain some cases .rarely chemical or rubber contraceptives
is present
2. Skin diseases not specific to the vulva: as scabies & seborrheic dermatitis
3. Urinary tract disorders glycosuria is almost the only condition associated with pruritus
4. Carcinoma of the vulva
5. Idiopathic pruritus
o International society for the study of vulvar disease (ISSVD) classification of
vulvar epithelial disorders :
Non neoplastic epithelial disorders Vulvar intraepithelial neoplasia(VIN)
1. Lichen sclerosis (hypoplastic dystrophy) 1. Squamous VIN: type I, II or III
2. Squamous hyperplasia (hyperplastic dystrophy) 2. Non squamous VIN:
3. Other dermatosis (scabies , psoriasis ,lichen planus , -paget’s disease
condyloma accuminata) -Melanoma in situ
o Lichen sclerosus et atrophicus:
Definition: non neoplastic epithelial disorder of the vulva- hypoplastic dystrophy
Incidence: the commonest condition found in the elderly women complaining of vulval itching but
may also be seen in children & young women
Aetiology: the cause is not known but it is associated with autoimmune disorders
Clinically: in early lesions the skin may be reddish or of normal colour
Later on it looks thin with a crinkled surface & white skiny plaques .the
Contour of the vulva slowly disappears & labial fusion may form
Microscopically: there is hyperkeratosis ,flattening of the rete pegs, & a zone of homogenized pink
staining collagenous appearing tissue beneath the epithelium .Lichen sclerosus is often associated
with foci of both hyperplastic epithelium & atrophic changes

50
 GYNA REVISION NMT11
Premalignant potential: It is uncertain if lichen sclerosus leads to vulvar cancer. VIN & lichen
scelorsus can coexist in the same patient. Approximately 4 % of women with lichen sclerosus
develop invasive cancer
Treament: topical application of testosterone ointment offers the best results
o Squamous cell hyperplasia:
Definition: Lesions of epithealial thickening & hyperkeratosis with no specific cause, the lesion may
have a dusky red appearance when degree of hyperkeratosis is slight. At other times well-defined
white plaques may be seen.Lichenification is seen frequently, while fissures & excoriation ,as a
result of chronic scratching ,may be present
Treatment: .hyperplastic lesions are best treated by local application of cortisone
o Nevus
- pigmented nevi occur on the vulva as they do else where ,but junctional activity, which carries a
risk for subsequent malignant transformation is more common in this location
- excisional biopsy should be performed on all pigmented lesions on the vulva for histologic
evaluation
- shouldn’t be treated by cryosurgery or laser therapy as histological examination is essential
Granulomatous caruncle
- It is a chronic infection of the periurethral tissue
- It is called a crauncle but is not neoplastic & is often symptomless
- It is often seen, while a true crauncle is uncommon
- Treatment is by cautery
- There is tendency to recurrence
- Infection in this area must involve the paraurethral gland network & complete cure is difficult
- A search should be made for a vaginal or bladder source of infection
o Premalignant lesions of the vulva :
A. Squamous VIN:
• 3 degrees (I,II,III), hyperplastic dystrophies with atypia
• Commonly occurs in the younger age where almost half of the cases are younger than 41
years
• Symptoms :1l3 of cases are asymptomatic ,however may presents as pruritus vulvae
• N.E. inspection: lesions are often raised above the surroundings skin with a rough surface
• Colour: variable (white due to hyperkeratinization, red due to thinning of epithelium, or
dark brown due to melanin deposition in the epithelial cells
• Multicentric lesions: VIN lesions are often multifocal, that is why wide excision is
mandatory

51
 GYNA REVISION NMT11
• Diagnosis: painting the vulva with 5 % acetic acid will result in VIN areas turning white &,
mosaic or punctuations will be visible by the N.E. or a hand held lens. Biopsies are taken
from aceto white areas to rules out invasive cancer
• Treatment :

Asymptomatic cases especially less than 50 years of age are managed
conservatively ,with repeated biopsies to exclude progression of the disease

Symptomatic cases are treated by topical steroids for 3-6 months to relieve
symptoms

If the lesion is small an excision biopsy may be both diagnostic & therapeutic

In wide & multifocal lesions ,skinning vulvectomy with or without skin graft may be
indicated

Close observation & re-biopsies are essential to detect invasive disease among those
who relapse. Repeated treatments are commonly required
B. Non squamous VIN :
1. Paget’s disease :
• Uncommon is similar to that found in the breast
• Presenting symptoms :pruritus
• Clinically: it often presents as a red crusted plaque with sharp edges
• Diagnosis: by biopsy, in almost 1l3 of cases there is an associated adenocarcinoma in the
apocrine gland & in 20 % concomitant cervical cancer mey present
• Treatment: by very wide local excision usually including total vulvectomy ,because unlike
VIN III the histologic extent of paget is frequently beyond the visible lesion
2. Melanoma: very rare
• Management of the invasive cancer of vulva:

Radical vulvectomy & en bloc groin dissection ,with or without pelvic lymphadencetomy has
long been considered the standard treatment for all operable patients ,resulting in a corrected 5
year survival rate of nearly 90 % for stages 1 & 2 disease. Such extensive surgery had a very high
morbidity affecting the quality of life after the procedure

During the past 20 years a number of significant advances have been made in the management
of vulvar cancer that have markedly decreased the physical & psychological morbidity
associated with the standard treatment :
1) Separate incisions are used for groin dissection; to decrease post operative wound
breakdown
2) Post operative pelvic & groin external radiation therapy ;has become the standard
treatment for patients with positive groin LNs, thus eliminating the need for routine
pelvic lymphadenectomy, unless metastases is documented in the inguinal node area

52
 GYNA REVISION NMT11
3) Very early tumors in which the depth of penetration is less than 1 mm, groin dissection
may be eliminated ,where a wide & deep local excision (radical local excision) is as
effective as radical vulvectomy in preventing in preventing local recurrence
4) In unilateral lesions on one of the labia majora, unilateral inguinofemoral
lymphedencetomy is an acceptable approach
5) For midline lesions invading more than 1 mm bilateral groin dissection is necessary
6) In advanced vulvar cancer involving the proximal yrethra, anus or rectovaginal septum
many centreshave been using preoperative radiation or chemo radiation to shrink the
primary tumor followed by more conservative surgical excision
o Prognosis of invasive cancer of the vulva:
• The 5-year survival rates ranges from nearly 90 % for stage 1 to 15 % for stage IV.
• Patients with nodal involvement have a 5 year survival rate 50% whereas those with no nodal
involvement have a 5 year survival rate about 90 %.
o Characters of normal vaginal discharge:
Clear in color, semi fluid in nature, with little or no small. PH ranges from 3.8-4.5(acidic) .amount
less than 0.5 ml/day
o Cysts of the vagina:
1. Cysts of vestigial structures :
a. Wallfian (mesonephric duct): the majority of vaginal cysts arise from gartner’s duct .they lie
on the lateral or anterolateral wall of the vagina from the lateral fornix downwards. They are
variable in size. The lining is a single layer of cuboidal epithelium
b. Mullerian (para-mesonephic): rare ,may be up near the cervix
2. Endometriotic cysts
3. Epidermoid cysts; implantion dermoid mainly due to obstetric laceration or episiotomy
o Vaginal neoplasms:
1. Benign neoplasms :
- Rare, some are paravaginal rather than vaginal, in that they arise in tissues in the paracolpos
- Common vaginal cysts include ;papilloma, angioma ,fibroma & lipoma
- Clinically they may be sessile or pedunculated
- Diagnosis; is by digital vaginal examination & naked eye speculum examination
- Treatment; surgical excision if large or infected
2. Vaginal intra-epithelial neoplasia(VAIN)
- An uncommon premalignant lesion of the vagina which is usually asymptomatic
- May be associated with neoplasia at other genital tract sites as VIN & CIN
- Diagnosis ;by an abnormal vaginal pap smear & confirmed by colposcopic examination of the
vagina

53
 GYNA REVISION NMT11
- Treatment will depend mainly on Laser destruction of the affected area. However, local excision or
the use of topical 5-flurouracil could be used
o Vaginl adenosis:
Is the presence of glandular- columnar epithelia & their mucinous secretory products in the vaginal
mucosa Adenosis is most often encountered on the upper anterior vaginal wall. It is glandular & red,
in contrast to smooth, pink squamous epithelium .there is a strong association between vaginal
adenosis & prenatal exposure to DES (diethyl stilbesterol) i.e. in daughters of women who took DES
during their pregnancy
o Urinary incontinence or chronic diarrhea may result in secondary vulvar reactions
o The use of soaps, perfumes, deodorant, & nylon or tight-fitting clothing especially in
a patient with an atopic history lead to vulvar affection.
o Definitive diagnosis of lower genital tract lesions requires biopsy, which is best performed
by a key’s cutaneous biopsy punch under local anaesthesia
o Vulval itching is the most common vulval complaint. It is the most commonly secondary to
vulvovaginal candidiasis, trichomonal infections, or lichen sclerosis et atrophicus
o Pruritus vulvae: refer to the intractable vulval itching in absence of a defined lesion
o Surgical treatment is effective especially in early disease with no nodal metastases
o In the recent years ,extensive radical surgery has been replaced by more limited but complete
surgery with adjuvant radiotherapy & sometimes chemotherapy
o vaginal cancers are among the rarest in the female genital tract affecting the older females
o early vaginal cancer may be treated by surgery or internal brachytherapy, while more advanced
stages are better treated with radiotherapy

Choriocarcinoma
For mcqs
o Incidence of choriocarcinoma:
It occurs in 1/50000 pregnancies, & is nearly 10 times higher in tha far-east countries than in other
regions in the world
o Gestational trophoblastic disease (GTD)
Spectrum of interrelated trophbalstic tumors including complete & partial hydatidiform mole,
placental site trophoblastic tumor including complete & partial hydatidiform tumor &
choriocarcinoma ,which varying propensities for local invasion & metastasis
o classification of gestational trophoblastic disease
Benign Malignant
Hydatidiform mole Choriocarcinoma

54
 GYNA REVISION NMT11
a) Complete mole a) Non metastatic
b) Partial mole b) Metastatic
-low risk -high risk

Fibroids
Exam questions

Discuss symptoms of fibroids (sep 97,june 99)

Give a short account on TTT of fibroids (march 95)

Discuss diagnosis & TTT of fibroids (june 00)

Discuss symptoms & signs & special investigations of uterine fibromyomata (sep 01)

Causes of metrorrhagia with uterine fibroids (june 2003)

TTT options in dealing with uterine fibroids (june 05)
For mcqs
o Aetiology leiomyoma :
The exact etiology is unknown, however possible aetilogical factors include:
A. Growth factors: may act synergistically with oestrogen in Induction of growth of myoma.

Increased production of epithelial growth factors

Decreased production of growth inhibiting factors.
B. Genetic factors: evident by the following:

40% of myomata show cytogenic abnormalities

Myomata are liable to recur after removal.
o Effects of fibroids on pelvic organs :
A. Uterus
The uterus is displaced in position resulting in
• RVF position ( may be caused by a fundal posterior wall myoma).
• Lateral displacement to one side ( may be caused by a broad ligamentary myoma).
• Upward displacement of uterus (may occur due to a large cervical fibroid).
B. Associated condition:
Endometriosis and adenomyosis, endometrial carcinoma (rare)
o Clinical picture of leimyomata:
• Polymenorrhea: Due to ovarian dysfunction
• Pressure symptoms :
- Broad ligamentary myoma and cervical ones may cause loin pain due to ureteric compression
and back pressure changes.

55
 GYNA REVISION NMT11
- Pressure of the enlarged uterus on the pelvic veins mat cause edema of the lower limbs, and
pressure on pelvic nerves may cause referred pain.
- Incarceration of a large myoma in the pelvic may cause acute onset of pressure symptoms.
• Uterine leiomyomata are an unusual case of infertility. They may by be associated with
infertility in 5-10% of the cases and are reported as a sole cause in <3% of cases.
• Abdominal mass:
May be the first symptom especially with subserous fibroids as no menstrual or pressure
symptoms occur. The patient may present with by progressive abdominal enlargement, with or
without pressure symptoms.
• Small uterine myomata, especially SMF, can be easily missed on clinical examination and need
further special investigations for proper diagnosis.
• Calcified myomata must be considered in DD of a calcified shadow on plain X-ray.
• Special investigations to establish diagnosis:
U.S.:
Considered as gold standard in the diagnosis of uterine leimyomata.
The sensitivity of TVS is highly improved in diagnosing SMF and small endometrial polyp
when coupled with saline injection of the endometrial cavity, a procedure known as saline
sono-hysterography.
• Special investigations to prepare patient for operations (preoperative investigations):
- Blood picture and haemoglobin
- Renal ultrasound and intravenous pyelography: in cases of cervical or broad ligament fibroid
to delineate the kidneys and course of the ureters.
- D&C: if the patient is complaining of premenopausal bleeding to exclude associated
endometrial carcinoma.
o Treatment of fibroids:
I. No treatment (expectant management)
Conservative management for asymptomatic small incidentally discovered fibroids is the
most appropriate treatment.
During pregnancy fibroids are always managed conservatively.
Indications to operate on symptomless fibroids_ add
- If diagnosis is doubtful (?ovarian)
II. Medical treatment

Indications: patients complaining of menorrhagia with uterine enlargement <12 weeks.

Aim: to control menorrhagia in women with small and moderate size myomata.

Medications used:
1- Progestins, Danazol and Anti-progesterone. They act by including pseudo-decidual
and atrophic changes in the endometrium. However, they are not always successful

56
 GYNA REVISION NMT11
especially with heavy bleeding or long term therapy (see hormonal treatment of
DUB).
2- LHRH Agonists: the most effective medication is GnRH agonist (e.g. Leuprolide
acetate 3.75 mg IM each month for 3-6 month i.e. temporary measure). It has the
advantage of inducing a reduction in the uterine size and reduction in the size and
vascularity of the myoma via its effect in producing a hypo-estrogenic state.

Disadvantages: associated hot flushes and risk of osteoporosis. Furthermore, rapid
regrowth of myoma occurs after cessation of treatment (hence it should not be used as
sole primary treatment of fibroids).
Indications for the use of LHRH Agonists:
a) Before Myomectomy: LHRH agonists treatment may allow adequate time to treat
anemia, to decrease size of myomata, and to minimize blood loss during the procedure.
However tissue plans around myomata become less defined with difficult enucleation
during surgery.
b) Before Hysterectomy: reduction in the size of the uterus may:
- Allow surgery via a low transverse rather than a midline abdominal incision.
- Facilitate an easier vaginal rather than abdominal hysterectomy.
c) In perimenopausal women: refraining from surgery in hope that cessation of ovarian
function at menopause will lead to control of menorrhagia, and atrophy of fibroid. Add
back therapy by low dose oestrogen or combined HRT may minimize hypo-oestrogenic
side effects.
o Uterine artery embolization:

Principle: therapeutic vascular embolization of uterine arteries by polyvinyl alcohol particles.

Aim: shrinkage of the size uterus and myomata and relief of menorrhagia thus avoiding
extensive surgery

Indication: in alternative hysterectomy only in elderly patient unfit or refusing surgery

Disadvantage:
- significant postoperative pain (like red degeneration)
- Weak uterine wall.
o Uterine polypi :
A. Corporeal
1. Adenomatous polypi: arise from the endometrium, either multiple in cases of marked
endometrial hyperplasia or single and is considered as adenoma of the endometrium. They
give rise to irregular uterine bleeding and treated by curettage followed by treatment of any
hormonal disturbances.
2. Fibroid polyp: firm mass with necrosed infected tip and long pedicle treated by
polypectomy.

57
 GYNA REVISION NMT11
3. Placental polyp: due to accumulated blood dote over the surface of retained piece of the
placenta giving rise to subinvolution and persistent bleeding after labour or abortion end
treated by curettage and microscopic examination to exclude chorio-carcinoma.
4. Malignant polyp: carcinoma, sarcoma or chorionepithelioma.
B. Cervical
1. Mucous polyp: one or more reddish soft polyp resulting from hyperplasia of the
endocervical epithelium due to chronic cervicitis. It’s treated by polypectomy followed by
treatment of chronic cervicitis. Any polyp removed should be examined histologically to
exclude malignancy.
2. Fibro-adenomatous polyp: it’s a mucous (adenmatous) polyp in which the stroma is dense
and fibrous.
3. Fibroid polyp: rare and appear as a firm polyp with necrosed tip attached to the cervix by a
short pedicle and treated by polypectomy.
4. Malignant polyp: either carcinoma, sarcoma or the rare highly malignant grape like
sarcoma of children which, is a mixed cell sarcoma characterized by rapid invasion and
formation of grape like mass of soft pinkish edematous polypi which fills the upper vagina.
5. Bilharzial papilloma: usually develop from the vaginal surface of the cervix. They may be
single, or multiple, sessile, or pedunculated, of variable size, firm in consistency, usually
rough and covered by intact grayish pink mucous membrane.
o Autopsy studies reveal a prevalence of up to 50%.
o They are usually multiple, and run a very gradual progressive course.
o Risk factors for leiomyomata include Nulliparity, obesity, positive family history & Racial
factors (fibroids are more common in black African women).
o Corporeal fibroids are commonly multiple, except for occasionally submucous or fibroid polyps
that may be single.
o When a submucous fibroid becomes a polypoid, usually the capsule ruptures and retracts.
o The muscle fibers are elongated with spindle shaped nuclei. Van Geison stain colors the muscle
cells yellow and fibrous tissue pink.
o Atrophy: decrease in size: due to diminished vascularity.
o Hyaline degeneration: this is the commonest change.
o Hyaline: homogenous structureless eosinophilic material staining pink with eosin, under
microscope, first affects fibrous tissue cells then muscle fibres.
o Cystic Degeneration: Microscopically, cavity lined by remnants of unabsorbed hyaline material
i.e. psuedocystic.
o Fatty degeneration: deposition of fat within the muscle cells. Its precursor of calcification.

58
 GYNA REVISION NMT11

o Necrosis: it also occurs following torsion of pedunculated subserous myoma.

o Difficult enoculation at operation, (absence of false capsule).
o Ureteric injury can be avoided by a preoperative IVP, ureteric catheterization and intra capsular
enucleation of myoma before clamping the uterine arteries.
o Fibroids don’t affect menstrual pattern if they are cervical or subserous.
o Amenorrhea with fibroids: think of pregnancy or menopause.
o Myomectomy

Indications:
a) Fibroids causing infertility (SMF, cervical, or myomata causing corneal tubal obstruction).
b) Fibroids causing recurrent abortions (SMF).

Contraindications:
a) During pregnancy or at Caesarian section (only if pedunculated subserous myoma)

Complications:
a) Increased morbidity due to higher incidence of postoperative fever, anemia, pain and ileus.

Types of Myomectomy :
A) Abdominal Myomectomy
Direct posterior wall incision, especially in low subserous myoma.
N.B. Uterine cavity need not be opened if no intrauterine pathology is revealed by
hysteroscopy and hysterography, but is opened especially in cases of patients
complaining of menorrhagia (so as not to miss endometrial polypi and small submucous
myomata).
B) Vaginal Myomectomy (only for fibroid polyp)
If pedicle is inaccessible  the polyp is twisted using volsellum.
C) Laparoscopic Myomectomy: (in selected cases)
It’s not widely practiced as OT’s a difficult procedure that requires special skills and
training.

Indications: Patients with a small number myomata (<4), of small size (<6 cm), mainly of
the subserous type (rarely intramural), provided the uterus is <16 weeks size.

Advantages include less postoperative adhesions, less pain, and better postoperative
recovery.

Disadvantages include: more difficult operation, longer operative time, and weaker
uterine scar.
D) Hysteroscopic Myomectomy (only for small myomata within the cavity) :
This procedure is more practiced for removal of submucous myoma <0.5 cm in diameter
which protrude >50% in the uterine cavity, provided the uterus is <12 weeks size. The

59
 GYNA REVISION NMT11
myoma is resected by diathermy, resectoscope or laser (better preceded by LHRH
agonist preparation)
Disadvantages: include the risk of perforation and/or fluid volume overload
o Hysterectomy
Hysterectomy includes surgical removal of the uterus including leimyomata.

Indications _
Whenever myomata are so large and multiple making myomectomy a high risk procedure

Advantages of Hysterectomy over myomectomy:
- Sure relief of symptoms with no recurrence
- Less blood loss during surgery and lower post operative morbidity.

Disadvantages:
Loss of further fertility and cessation of menstruation after removal of uterus

Types of hysterectomy:
A) Abdominal hysterectomy
Is a commonest and safest route of surgery as the uterus is usually markedly enlarged
and the anatomy is distorted by multiple myomata.
• Total Abdominal hysterectomy (TAH):
Which entails removal of the whole uterus including the cervix, is the operation of choice, as
it avoids the rare risk of developing future stump carcinoma? However the procedure is more
difficult, lengthy and associated with greater risk of bladder and ureteric injury when
compared to subtotal hysterectomy.
• Subtotal hysterectomy (with preservation of the cervix) is a reasonable alternative
whenever we are met with extensive pelvic adhesions or endometriosis or whenever it’s
indicated to minimize the operating time and procedures in the obese and high risk
cases.
In a relatively young patient, subtotal hysterectomy may be preferable to preserve the cervix
for better sexual activity and better support of the vault, provided that the cervix is healthy
with no history of risk factors and preoperative smear proved to be normal.

Ovarian conservation: during total or subtotal hysterectomies, the ovaries are usually
preserved to maintain their hormonal function and oestrogen production. They are
surgically removed during the procedure only if the patient is menopausal or >50 yr of
age or if there is associated ovarian pathology that necessitates oopherectomy (i.e.
benign cyst suspicion of malignancy, infection…etc)
B) Vaginal Hysterectomy: maybe attempt if the uterus is <12 week size with small
myomata specially in cases associated with moderate degrees of uterine or utero-vaginal
prolapsed.
Cancer cervix

60
 GYNA REVISION NMT11

Exam questions

Precancerous lesions of the cervix & then prognosis (sep 90)

Discuss early diagnosis of carcinoma of cervix (july 95)

Discuss diagnosis & TTT of carcinoma of the cervix (june 01)

Lymphatic spread of carcinoma of the cervix (feb 99,03, 05)

Lymphatic drainage of the cervix (04)

Give a short account on clinical stages of cancer cervix (sep 89)

Discuss carcinoma of the cervix (feb 04)

Clinical staging of carcinoma of cervix (R 05)
For mcqs
o Cervical intraepithelial neoplasia (CIN), may occur at any age, however it’s commoner in the
younger age groups 25-45 years. It’s usually present several years before the occurrence of invasive
and pre-invasive diseases, and is considered as a premalignant lesion.
Pre-invasive carcinoma (carcinoma in Situ) occurs mostly between 35-45 years.
Invasive carcinoma of cervix prevails mostly at ages from 45-60 years, with a peak incidence around 50
years, an age incidence which is nearly 10 years earlier than that for endometrial carcinoma.
o Relation between HPV & CIN?
Forms of HPV, a virus whose different types cause skin warts, and other abnormal skin and body
surface disorders, have been shown to lead to many changes in cervical tissues that may eventually lead
to cancer.
The virus may provide the genetic material for cells at the squamo-colomnar junction within the
transformation zone of the ecto-cervix, which will later provide malignant epithelium. Because HPV can
be transmitted by sexual contact, early sexual contact and having multiple sexual partners have been
identified as strong risk factors for the development of cervical lesions that may progress to cancer.
In the majority of women who have been exposed to the genital form of HPV, the immune system will
get rid of the virus without them even knowing of its presence. In others, the virus will remain present
for a number of years, and due to low immunity and repeated exposures, precancerous changes may
occur in cervical cells resulting in what is known as cervical intraepithelial neoplasia (CIN).
CIN, if left untreated, may develop to cancer in some women, however it’s important to mention that
most women with CIN do not develop cancer. CIN may also be referred to as dysplasia.
The type of HPV present can affect whether the CIN develops into cancer or not. Only certain HPV
types such as 16,18,31 and 33 seem to be associated with the development of cervical cancers.
It’s important to note that many cases, which will develop cervical cancers, have been exposed to HPV
or other risk factors. Such cases are genetically determined and not much affected by many of the
above mentioned risk factors.
o Clinical presentation of cancer cervix

61
 GYNA REVISION NMT11
Clinical symptoms
- Vaginal bleeding: is the most common presenting complaint. It may be either:
a) Contact bleeding i.e. after coitus or douching (commonest)
b) Metrorrhagia Intermenstrual
c) Postmenopausal bleeding
d) Persistent bleeding during pregnancy (rarest)
- Vaginal discharge:  profuse & resistant to conventional treatment
- Other symptoms Pain: sciatic or obturator nerve affection
Clinical signs
- General examination:
a) Early cases: good general condition and relatively young age
b) Advanced stages: sever uraemia anaemia & cachexia due to chronic blood loss, urinary
manifestations & ureteric obstruction.
- Inspection via speculum:
a) invasive cancer cervix small nodule/ ulcer blleds easily on touch
b) later on friable warty mass, which may break into a large ulcer
c) Advanced cases lesion extends to vaginal walls , obliterating the vaginal fornices.
- Bimanual pelvic examination:
a) Normal in size (usual)
b) Symmetrical uterine enlargement  pyometra present
c) Asymmetrical enlargement leiomyomata accidently present
o Treatment of CIN
CIN treatment depends on its severity. In general the management is usually conservative
requiring no or very limited surgical techniques.
- CIN I  follow up = repeat smear test after 8-12 weeks.
Techniques
A) Ablative technique:
It's essential to exclude invasive disease FIRSTbecause in contrast to excisional methods, no
tissue will be available for histological examination.
Forms of ablation
- Cryosurgery: allows destruction of affected epithelium by freezing to a depth of 3-5mm. It's
quick, sufficiently painless and done without general anaesthesia.
- Diathermy: under general anaesthesia, destroys tissues to a depth of >7 mm.
- CO2 Laser: results in tissue vaporization to a depth of 7-9 mm. With maximum precision and very
minimal trauma.
B) Excisional techniques:

62
 GYNA REVISION NMT11
Excisional techniques have the advantage of both treating the condition and obtaining tissue
samples available for histological examination, where the original diagnosis maybe confirmed,
disease free margins established, and invasion of basement membrane excluded.
- Large Loop Electrodiathermy of the Transformation Zone (LLETZ):
A thin wire loop is used to excise the transformation zone using a blended diathermy current. It’s
rapid, cheep, safe and easy, hence it became the most popular technique in most centres.
- Knife cone biopsy:
Less common nowadays because it’s associated with higher incidence of bleeding, infection,
cervical stenosis and cervical incompetence in subsequent pregnancies.
- Laser cone biopsy:
Less commonly used as it’s more expensive, needs complicated instruments, done under
general anaesthesia, and requires special training and experience.
N.B.: Follow up after treatment:
Despite the efficacy of the above mentioned techniques in treating CIN, yet recurrence is still
common, and follow up by annual Pap smear is recommended for a period of up to 10 years.
o Treatment of carcinoma in situ (Stage 0)
1- Cervical conisation: only in young patients with low grade tumors and wide free surgical
margin after excision. Aim is to preserve uterus for fertility.
2- TAH (Total abdominal hysterectomy): In middle aged patients not desirous of fertility. Aim is
to remove the cancer and preserve ovarian hormonal production.
3- TAH-BSO (TAH+ Bilateral salpingo-oophorectomy): in premenopausal or postmenopausal
patients. Lymphadenectomy is not required as there is no invasion of basement membrane.
o Treatment of Microinvasive Carcinoma (stage Ia)
TAH-BSO. Patients may be spared a complete lymphadenectomy, or maybe offered only
selective lymph node sampling to minimize extent and morbidity of surgery.
o Treatment of other stages of invasive cancer
Choice of therapy Based on:
1- Stage of disease
2- Grade of tumor
3- Age and general condition of patient
4- Availability of well trained team for both surgery and radiotherapy.
Results of surgery and radiotherapy
Both are compatible in early stages of the disease; however surgery is more preferred as it
allows for complete resection of the tumor and provides a specimen available for ensuring the
extent of the disease.
In more advanced stages,

63
 GYNA REVISION NMT11
The high morbidity of extensive surgery and possible distant spread of the disease are in favour
of choosing the option of radiotherapy.
The prognosis in Stage I,
Disease is excellent with 5 years survival rates of 80-85%, whether surgery or radiotherapy were
used.
The prognosis in Stage II,
Drops sharply to a 5 year survival of 50%.
In stages III & IV,
5 year survival may be as low as 25% and 5% respectively. The treatment in these stages is
therefore only palliative.
Factors affecting prognosis,
Include clinical signs of the disease, histopathologic type and the degree of differentiation.
A) Surgery in Cancer Cervix
Where the disease is confined to the cervix, surgery is usually the first line of treatment (stage IA
& I B). In this situation, radiotherapy is as effective as surgery but the side effects are greater,
and the morbidity is higher.
B) Radiotherapy in Cancer Cervix
If cancer has spread beyond cervix (Stages II & III), it will not be curable by surgery and therefore
Radiotherapy becomes the preferred first line of treatment.
It may be given alone, or in combination with surgery or chemotherapy.
External beam irradiation:
- Treats: whole pelvis
- Used: to shrink the central carcinoma
- Can also treat regional sites of distant metastases.

Internal irradiation:
- Placed in: upper vagina and within cervical canal,  to provide a very high dose to central
tumor.
- Method: 2 internal applicants (tandum & ovoids) are usually inserted within a week after
completing the external beam therapy (which usually requires 5 weeks)

Combined radiotherapy and chemotherapy: (see chemotherapy)

Postoperative Radiotherapy:
- Indication: * if more than 1 lymph node is positive
* If tumor margins are very close
* If the tumor was bulky and has a high chance of recurrence.

64
 GYNA REVISION NMT11
Palliative radiotherapy:
In advanced cancer cervix (Stages III & IV), radiotherapy may be used in palliative settings to
reduce vaginal bleeding and discharge and to assist in local control of central disease.
C) Chemotherapy in Cancer Cervix
Recently studies have shown that the addition of chemotherapy during radiotherapy increases
cure rates by approximately 10%.
Chemotherapy may be also used in adjuvant settings prior to surgery to reduce the size of the
primary tumor. In some cases it will be used in adjuvant setting following surgery.
Chemotherapeutic drugs include: Cisplatinum, Bleomycin, Mitomycin and Adriamycin.
• In early pregnancy medical induction of abortion using oral and vaginal tablets of
mesoprestol (prostaglandin inhibitor) is also possible to cause abortion.
• In 2nd and 3rd trimesters many surgeons will prefer to treat these cases with Wertheim’s
radical hysterectomy at the time of Caesarean section.
• Carcinoma of cervical stump after hysterectomy: internal irradiation is compromised by
the absence of the uterus as a container for intrauterine applicators, while vaginal
irradiation may not deliver the sufficient dose without the risk of damage to bladder and
rectum.
• Surgery (radical cervicectomy and lymphadenectomy) is complicated by the presence of
adhesions and abnormal anatomic relations produced by previous hysterectomy.
o Recurrent cervical cancer:
A) Recurrence after primary surgery
Add: “is treated palliatively by external beam irradiation. Aim  control bleeding, pain and
infection. Prognosis is poor in all conditions.

B) Recurrence after Radiotherapy

Palliative surgery through pelvic exentration maybe considered.
- Aim control pain, bleeding and infection.
- Types of Exentration:
Maybe anterior (involving uterus and vagina)
Posterior (involving rectum)
Total (involving both)
- Operation carries very high morbidity and mortality and is rarely resorted to.
o Palliative therapies in cancer cervix:
Advanced cases of stages III & IV require special care aiming at amelioration of symptoms, control
of pain, bleeding and infection.
Palliative measures include:
- Palliative medications for pain relief: Pethidine, morphia

65
 GYNA REVISION NMT11
- Palliative surgeries for fistulas, colostomies & ileal bladder
- Palliative radiotherapy
- Presacral neurectomy
- Nerve block procedures.
o Cervical cancer is highly correlated with HPV infection and less commonly HSV type II.
o Screening by PAP smears for high risk cases will allow prevention and early detection of most
lesions.
o A positive smear warrants repetition and colposcopic guided biopsies if confirmed.
o On average CIN will advance to invasive cancer in about 7 years, and CIN II in 4 years.
o CIN I may be followed by colposcopy every 3-4 months, and infection treated.
o CIN II may be treated by destruction of the lesion by cauterization, cryo or laser therapy.
o CIN III is best surgically removed by conisation using LEEP procedure or cold knife. Hysterectomy is
another option in the elderly patient.
o Contact bleeding is the most common presenting symptom for invasive cancers.
o Biopsy from a suspicious cervical lesion (ulcer or a friable mass) is the gold standard for diagnosis.
o Treatment of Stage 0 is surgical by conisation in the young patient and TAH in the elderly.
o Stage I A is best treated by TAH, with or without BSO, with no need to lymphadenectomy.
o More advanced stages are either treated by Wertheim’s hysterectomy or radiotherapy.
o Radiotherapy whether as a primary treatment or as adjuvant therapy has an important role in
cancer cervix.
o Schiller’s iodine test:
paint: “lugol’s iodine”
o One of the key features of cancer cervix is the slow progression from normal cervical
epithelium to precancerous changes (CIN) to invasive cance
o low socioeconomic standards and poor hygiene (chronic irritation) is a Risk factor for cancer
cervix
o (reason for smoking being a factor) chemicals in cigarettes may interacts with cells in cervix)
o The squamo-columnar junction in younger females is nearer to the external os, which makes
cells more exposed both to a low vaginal PH and to foreign DNA derived from male semen and
sexually transmitted viruses.
o the transformations zone is that area in the ecto-cervix that was covered by columnar
epithelium and through the process of metaplasia becomes replaced by stratified squamous
epithelium.
o The ecto-cervix epithelium consists of 4 layers:
Basal cells
Para-basal cells

66
 GYNA REVISION NMT11
Intermediate cells
Superficial cells
o The term CIN has been proposed to describe a spectrum of intraepithelial changes occurring
within the squamous epithelium of the ecto-cervix. These changes include:
-increased proliferation of cells
-inhibition of maturation (increased amount and number of immature cells)
-pleomorphism: disparity in the shape of cells
-loss of polarity
o The term dysplasia (disordered growth) has been formerly used to describe these epithelial
changes that are now referred to as CIN. In cytology, a dysplastic cell is a cell with an abnormal
nucleus, cytoplasm being free.
o In general, CIN is an asymptomatic condition, at least in its milder forms, and is usually diagnosed
during screening for cervical cancer by PAP smear.
o Endo-cervical carcinomas
Macroscopic picture
By the time the tumor appears in the external os, the carcinoma has often spread extensively
outside the cervix. They are therefore, diagnosed somewhat later than ectocervical cancers, which
are easily diagnosed even by naked eye on routine speculum examination.
Microscopic picture (in both ecto & endo carcinomas)
Squamous cell carcinomas:
-the commonest type (>90%)
-develops from the flat cells, which cover the outer surface of the cervix (ecto-cervical carcinoma of
the portio vaginalis). However, it may rarely arise in the endo-cervix due to previous squamous
metaplasia.
-It’s easily and early detected by Pap smear test.
Adenocarcinoma:
-less common (<10%)
-develops from the glandular epithelium, which lines the cervical canal (endo-cervical carcinoma),
or remnants of the Wolffian duct.
-Being within the endo-cervix, it may be more difficult to detect with smear tests.
o Degrees of differentiation (histological grading of cancer cervix)
Well differentiated (Grade 1) cells resemble the normal squamous epithelium of the cervix. They
grow slowly and are less likely to spread.
Moderate and poorly differentiated (Grades 2 & 3) poorly differentiated cells look very abnormal
and don’t resemble squamous epithelium. They grow more quickly and are more likely to spread
early. Cervical carcinoma is predominantly of the moderate or poorly differentiated types.

67
 GYNA REVISION NMT11

o Premalignant lesions of the cervix (CIN), can be detected by performing cytological

examination of cervical smears in all women (screening), or at least high-risk cases, and performing
colposcopy in women with abnormal smears.
o Cytology (pap smear)
The smear, or PAP test, is commonly used as a routine test to detect early cell changes
(dyskaryosis). This is known as cervical screening and is aimed at women with no symptoms;
however it’s sometimes used to help diagnose cervical cancer.
o Advantages of Cytology (pap smear)
-simple (can be carried out as an out-patient procedure)
-allows early detection of malignancies, before symptoms, with an accuracy exceeding 95%.
o Mechanism Cytology (pap smear)
The discharge is spread on a glass slide fixed by ethyl alcohol and stained by Papanicolau stain
o PAP smear results may either be:
-Normal: No inflammation, no CIN
-Inflammatory without dysplasia. NO CIN
-CIN I: mild dysplasia or dyskariosis
-CIN II: moderate dysplasia or dyskariosis
-CIN III: sever dysplasia (In situ carcinoma) invasion may be suspected.
o Colposcopy:
A colposcope is like a small microscope with a light that allows binocular inspection of the
ectocervix up to the squamo-columnar junction within the transformation zone with a
magnification up to 20 times the normal size.
If the smear test is abnormal, a colposcopic examination will be useful in visualizing abnormal
areas showing abnormal vascularity by use of green filters.
In abnormal findings colposcope
-punctuation & mosaic pattern  indicate abnormal vascularity.
o Schillers Iodine
- Indication: in cases where a Pap smear is positive or suspicious, and in absence of a naked-eye
lesion and unavailable colposcopic examination facilities.
- Histologic examination of biopsies from unstained areas will confirm diagnosis.
o Cervical biopsies
- Histopathologic examination of a specimen of cervical tissue containing the abnormal
epithelium is the GOLD standard technique for diagnosis of cervical cancer.Pathological
examination will define the type of malignancy (squamous or Adenocarcinoma), differentiate
between invasive and preinvasive disease, detect microinvasion, and evaluate the grade of
malignancy (low, moderate or high).

68
 GYNA REVISION NMT11
- Technique:
- Under general anaethesia
- Knife biopsies: obtained from suspicious lesions seen by naked eye
- Coploscopic directed biopsies: from suspicious areas under coploscope (without anaesthesia)
- Multiple punch biopsies: from the four quadrants, in absence of naked eye lesions.
- Cone biopsies: removal of a cone shaped piece of the cervix with the apex of the cone including
the transformation zone.
- Disadvantages:
- Excessive bleedingmay lead to scarring, stenosis and and later cervical incompetence.
-
Endometrial carcinoma
Exam questions

Discuss carcinoma of the endometrium (june 96)

Discuss the treatment of endometrial carcinoma(feb 97)

Discuss the pathology , diagnosis and treatment of carcinoma of the endometrium (feb 94,feb
98 ,june 04 )

Discuss the pathology , clinical picture and treatment of carcinoma of the body of the uterus
(sep 92 )
For mcqs
o Sites of endometrial carcinoma :
Fundus, the tubal corners and the isthmus. These are the sites of the strongest hormone
influence in the lining endometrium.
o Spread of endometrial carcinoma :
1. Direct spread, endometrial carcinoma usually spreads first on the surface of the
endometrium, called surface rider tumour filling the whole uterine cavity. By direct spread
which depends on how much the tumour is differentiated. Less differentiated EC are more
aggressive with tendency to early and deep myometrial invasion
2. Lymphatic spread, spread to lymphatic channels will worsen the prognosis and modify the
standard treatment
3. Vascular spread, cell from carcinoma get detached from the main mass and are taken by the
flow to other organs and parts of the body. Such metastases may invade the ovaries, adnexa
or the vagina as near by organs with poor prognosis, or may be carried to distant organs as
liver, lung ,brain and bones where the disease reaches a terminal stage, and the treatment
becomes only palliative

o Grading and Staging :

69
 GYNA REVISION NMT11
1. Well differentiated tumours (grade 1) consist of glandular formation with less than 5% solid
parts they are slowly invasive and carry the best prognosis
2. Poorly differentiated tumours (grade 3) consist of more than 50% solid parts, they are highly
aggressive with early deep myometrial invasion and poor prognosis
3. Moderate (stage 2) carry intermediate prognosis
o Surgical staging: is performed during laparotomy to evaluate the depth of myometrial
invasion. The presence of malignant cells in peritoneal wash and the presence of positive lymph
affection. Those in addition to the grade of the tumour will determine the extent of the surgical
procedures, the need for adjuvant radiotherapy, the chances for cure and the prognosis for each
case individually
o Prognosis :
Good prognosis with >85% 5 years survival when diagnosed in stage 1. Grade 3 have a poorer
prognosis stage by stage compared to grade 1 and 2. The presence of tumour cells in the
peritoneal cavity detected by cytology from peritoneal wash will upstage the tumour from stage 1
to stage 3.
o Presentation of the patient in medical care :
Bleeding, which is usually profuse, persistent and recurrent even after attempts using medical
treatment?
o Treatment of sage III in many cases is only palliative rather than curative and this may limit the
extent of surgical intervention.
o Progestagens: These are synthetic progestational compounds (progestagens) have long been used
for prevention of endometrial carcinoma in high risk cases by correcting the unopposed effect of
estrogen on endometrial cells.

Ovarian neoplasms
Exam questions

Pathology of benign cystic ovarian tumours(mar 93)

Benign cystic teratoma (dermoid cyst) of the ovary(sep 01)

Pathology , diagnosis and treatment of benign cystic neoplasms(june 98)

Clinical picture , complications and treatment of benign ovarian tumours(june 02)

TTTof benign ovarian tumors (june 03,may 04,R 05)

Complications of benign ovarian tumors (june 04 ,R 01)

Criteria of malignancy in ovarian tumours((feb 04)

Early diagnosis , clinical picture , investigations , treatment and prognosis of malignant
ovarian tumours(sep 88)

Clinical picture & TTT of malignant ovarian tumors(89)

70
 GYNA REVISION NMT11

Cp of benign & malignant & complications of ovarian tumors(sep 91)

Complications of ovarian tumors(june 00)

Complications & TTT of benign ovarian tumors(2000)
For mcqs
o Germ cells tumour could be either:
Differentiated Undifferentiated
Embryonic tissue (teratoma) No evidence of differentiation into
Extraembryonic tissue: embryonic or extraembryonic tissue.
Yolk sac: Endodermal sinus tumour Dysgerminoma
Trophoblast: choriocarcinoma
o benign tumours of the ovary :
Benign surface Benign germ cell Benign sex cord
epithelial tumor tumor stromal tumours
Incidence Commonest Less common Least common
Origin Surface epithelium Germ cells Sex-cord or Ovarian
stroma
Types
Cystic Cystic
- Serous cystadenoma - Benign cystic
- Mucinous cystadenoma teratoma (BCT)
- Endometrioid Solid
cystadenoma Solid - Fibroma
- StrumaOvarii - Thcca cell tumour
Solid - Gonadoblastoma
- Brenner tumour
o Struma ovarii :
It is composed of hormonally active thyroid tissue. It comprises only 1-4% of cystic teratomas. Only 5%
produce sufficient thyroid hormone to produce symptoms. Some 5-1:0% of tumours develop into
carcinoma. Struma ovarii is the most common type of monodermal teratoma.

o “Gonadoblastoma” :
It is a benign solid tumour composed of germ cells mixed with other cells resembling granulosa and
Sertoli cells.Although gonadoblastoma is initially benign, half of these tumours may predispose to
development of Dysgerminoma or other malignant germ cell tumours. Almost all patients with a go-
nadoblastoma have an abnormal gonad, with a Y chromosome in 90% of cases.
o complications of benign ovarian neoplasms:
1. Torsion
Treatment:
Ovarian cystectomy: untwisting of the pedicle and removal of the cyst with preservation of the
ovary has a place if there is still adequate healthy ovarian tissue present.

2. Rupture:

71
 GYNA REVISION NMT11
Clinical picture: Bleeding in the peritoneal cavity gives the picture of internal haemorrhage
(abdominal wall rigidity, tenderness, rebound tenderness, dull flanks and shifting dullness if
haemorrhage is severe).
3. MALIGNANT TRANSFORMATION:

Potential of malignancy is higher in solid rather than cystic tumours.

Papillary serous cystadenoma has the highest potential to malignant change (up to 50%).

Mucinous cystadenoma has a 5% incidence of malignant transformation.

Benign cystic teratoma carries the least potential of malignancy in less than 1%.
o Treatment of benign ovarian neoplasm :
1. Ovarian Cystectomy:
Consists of shelling out or enucleation of the cyst with preservation of the ovary. It is indicated in
young patients and particularly with bilateral cysts as in dermoid cyst. Ovarian cystectomy may be
done either by laparotomy or by laparoscopy.
• Laparoscopic ovarian cystectomy is best reserved for the young women (<35 years) with small sized
cyst. Cyst fluid may be sent for cytological examination. Dermoid cysts are better removed by
laparotomy rather than laparoscopy as laparoscopic surgery may carry the risk of dissemination of
the contents.
2. Oophorectomy:
Consists of removal of the whole tumour together with the ovary. The word ovariotomy is a
synonym still used by tradition to describe the same procedure however; oophorectomy is the
more correct term. Both the infimdibulopelvic ligament, (lateral to the tumour and contains the
ovarian vessels, nerves & lymphatics), and the ovarian ligament (medial to the tumour and
attached to the uterus), are clamped and double ligated. The mesovarium can be clamped
separately.
3. Panhysterectomy:
If the patient is premenopausal, and has completed her family, total abdominal hysterectomy with
bilateral salpingo-oophorectomy (TAH BSO) is usually indicated. This is considered as a preventive
step against the future development of ovarian cancer in advancing age.
o Malignant ovarian tumours
Malignant epithelial Malignant germ cell Malignant sex cord stromal
tumours tumours tumours
Incidence Commonest Less common Least common
Origin Surface epithelium Germ cells Sex-cord or Ovarian stroma

Types - Serous -Dysgerminoma - Granulosa cell tumour

adenocarcinoma
- Mucinous -Endodermal sinus - Sertoli-Leydig cell tumour
adenocarcinoma tumour
- Endometrioid
adenocarcinoma -Choriocarcinoma
- undifferentiated
adenocarcinoma -Solid teratoma

72
 GYNA REVISION NMT11

o Incidence:
Primary ovarian epithelial cancer forms 60-70% of all ovarian tumours, and 90% of all ovarian
malignancies. It is the third common malignancy of female genital organs, after cancer of endo-
metrium and cervix, however it is the most lethal.
o Aetiologies :
1. Reproductive factor
Nulliparous or infertile women are more liable to develop epithelial ovarian cancer, possibly due to
the continuous repeated minor trauma of the surface epithelium of the ovary caused by unin-
terrupted ovulation.
2. Hereditary factor
Three types of familial ovarian cancer are identified:
a. Site specific ovarian cancer syndrome (15%)
b. Hereditary breast / ovarian cancer syndrome (75%)
c. Hereditary non polyposis colorectal cancer syndrome with endometrial, breast, or
ovarian cancer (10%).

o Risk factors for epithelial cancer :

1. White race: have more prevalence compared to black and African women

o Pathology of primary epithelial ovarian cancer :

• Macroscopic appearance:
Usually solid but may be partially cystic partially solid. It may be unilateral or bilateral. The substance
of the tumour is the seat of extensive haemorrhage and necrosis.
• Microscopic picture: It is an Adenocarcinoma which might be either:
a. Well differentiated (Gr I). showing a preserved glandular pattern;
 Serous cystadcnocarcinoma
 Mucinous cysadenocarcinoma
 Endometrioid cysadenocarcinoma
b. Moderately differentiated (Gr II); showing glands and sheets of highly malignant cells
c. Undifferentiated (Gr HI); showing sheets of highly malignant cells.
These are tumours of low malignant potential as it is confined to the ovary. Tumours are mostly se-
rous or mucinous, they occur in younger age, and usually have a better prognosis.
o Some of Special features in germ cells tumours :
1. They are the commonest tumours of abnormal gonads and in sex chromatin negative females
2. They tend to grow rapidly resulting in pelvic pain and pressure symptoms occurring early in the
disease process
3. Most tumours produce substances in the circulation that can be used as tumour markers;

73
 GYNA REVISION NMT11
 Dysgerminoma secretes alkaline phosphatase and lactic acid dehydrogenase
 Endodermal sinus tumour elaborates alpha feto proteins
 Although benign Struma ovarii secretes thyroxine in 15% of cases
 Choriocarcinoma and other germ cell tumours elaborate hCG

4. In contradictinction to epithelial tumours, germ cell tumours are radiosensitive, chemotherapy

in some of them gives excellent results in stage Ia
5. Conservative surgery in the form of salpingoopherectomy is the first line of treatment in these
tumours as the patient is usually young, although the tumour is border line or malignant
o MALIGNANT SEX-CORD STROMAL TUMOURS
Sex-cord stromal tumours may arise from non- functioning or functioning stroma of the ovary
1. Functioning sex-cord tumours may be:
- Estrogenic, as granulosa cell tumour.
- Androgenic: as Seitoli-leydig cell tumours
- Both estrogenic and androgenic effect (very rare): as in Gynandroblastoma.
2. Non- functioning stroma may very rarely give rise to fibrosarcoma of the ovary.
o Patterns of spread of ovarian cancer :
There are three primary methods of spread of ovarian cancer:
1. Direct extension to adjacent organs such as tube, uterus, colon and bladder
2. Transcoelomic spread, by exfoliation of surface cells into the peritoneal cavity. Metastases are
typically seen in Douglas pouch, right paracolic gutter, right lobe of liver, right hemidiaphragm
and surface of intestine or omentum (pathway of peritoneal fluid)
3. Lymphatic spread mainly to paraortic lymph nodes.
4. Haematogenous spread is always late and uncommon. This would be to vital organs such as
liver, lung, brain and bones.
o Metastatic Ovarian Cancer
Prognosis:
Bad prognosis, most patients die within one year because most of the lesions are not discovered until
the primary disease is advanced.
Special investigations:
• Paracentesis: needle aspiration of ascitic fluid for cytologic examination
• Endometrial curettage : in cases of abnormal uterine bleeding to exclude a primary or spread to
uterus
o Chemotherapy in ovarian cancer :
1. Early stage disease: It has a limited place only with poor prognostic factors as Poorly differenti-
ated tumours, ruptured capsule, or +ve peritoneal wash (even in stage I cases).
2. Advanced stage disease: Chemotherapy is indicated in all cases of stage II-IV disease.
a. All cases after primary cytoreductive debuIking surgery
b. Palliative therapy in patients with irresectable tumours, or patients with recurrent disease

74
 GYNA REVISION NMT11

o Types of chemotherapy used in managing ovarian cancer :

Chemotherapy is usually recommended as soon as possible after surgery, and is given for five
or six cycles at 3-4 weekly intervals.Chemotherapeutic agents include: Cisplatin or
Carboplatin alone or in combination with Paclitaxel (Taxol).
o Signs of toxicity from chemotherapy :
Nausea, vomiting, myalgia and arthralgia. In severe cases renal damage, peripheral neuropathy,
hearing loss, dehydration and electrolyte imbalance may occur.
o Radiation therapy in ovarian cancer :
As an adjuvant therapy following cytoreductive surgery in patients who refuse or are not good
candidate for chemotherapy. Two main forms are used:
1. Intraperitoneal radioactive colloids or
2. Whole external beam abdominal radiation.
o Paraovarian cysts
Definition: Parovarian cysts are not ovarian in origin. They arise from cystic dilatation in the
Wolffian ducts remnants in a tubule of the epoophoron between the layers of the broad ligament
just below the fallopian tube.
Pathology:
Parovarian cysts are rarely over ten centimeters. They are covered by peritoneum, and the fallopian
tube is characteristically stretched over their upper surface. They are thin-walled, unilocular, and lined
by flattened epithelium (cubical) and contain clear fluid. They do not tend to be malignant.
Clinical picture:
They are usually asymptomatic, incidentally discovered during regular pelvic examination, during
pelvic ultrasonography, or during laparotomy or laparoscopy for any other condition.
Diagnosis:
• Clinically: Parovarian cysts are differentiated from ovarian cysts by their fixity and the displace-
ment of the uterus to the opposite side. They differ from hydrosalpinx by being free of any
tenderness and by being uni-lateral.
• On ultrasonography: the cyst is unilocular, thin walled, echolucent, with no internal echoes or
solid areas. The ovary can be seen separate from the cystic mass especially on TVS.
• At operation: the nature of the cyst is recognised by finding the Fallopian tube stretched over it and
by the fact that the ovary is separate from the cyst, usually attached at a point on the posterior surface
of the cyst.
Treatment:
Treatment of parovarian cysts consists of removal of the cyst by enulceation after incising the
overlying peritoneum. The cavity left is obliterated by sutures and complete haemostasis is ensured to
prevent haematoma formation. The procedure can be performed both by laparotomy or laparoscopy
according to tumour size and surgical facilities. In the case of large cysts burrowing deeply in the pelvis
care is required not to injure the ureter or uterine artery.
o Malignant ovarian tumors are usually primary but may be rarely metastatic .
o In BCT there is usually predominance of the ectodermal structures.

75
 GYNA REVISION NMT11

o Prophylactic gonadectomy should be performed in patients with dysgenetic gonad, particularly

with a Y chromosome for fear of future development of malignant neoplasms.
o BCT is the commonest cyst to undergo torsion because of its long pedicle and huge fat content.
o Diagnosis of benign ovarian tumors is best achieved by bimanual vaginal examination and
ultrasonography in most cases.
o Most tumours will be stage II or III when first discovered due to the absence of specific symptoms
in early disease. The prognosis is generally poor if tumour is first discovered beyond stage 1 disease.
o A staging laparotomy is indicated in every malignant ovarian tumour regardless its clinical I
staging. During laparotomy removal of the main tumour bulk is performed together with peritoneal
fluid cytology, omenetectomy, and Lymph node sampling in order to assess the extent of the disease,
the prognosis and the need for adjuvant therapy.
o Primary cytoreductive surgery in advanced disease aims at removal of maximum tumour bulk
leaving tumour residues less then 2, 0 cm to facilitate postoperative chemotherapy.

Contraception
Exam questions

Discuss the methods of birth control(june 96)

Intra-uterine contraceptive devices(march 94)

Side effects ,complications and contra-indications of IUD(june 98)

Contraindications of IUD (sep 88)

Complications of IUD(june 02,04)

Inability of the woman to feel the nylon threads of the IUD(june 90)

Contraception for a lactating female(sep 89)

Mode of action of oral contraceptive pills(june 00,01)

Contraceptive pills(sep 93)

Local chemical contraceptives(feb 98,sep 00)

Contraindications of contraceptive pills(2003)

Side effects of combined oral contraceptive pills(sep 89)
For mcqs
o the safe period
It is the period in which unprotected sex can occur, before 10th day and after day 19th of the menstrual
cycle. Between days 10th-19th, intercourse will be prevented or protected by a barrier method or coitus
interruptus.
o One of relative contraindications for OCP use is Superficial thrombophlebitis
o the candidates for pill use

76
 GYNA REVISION NMT11
<35 years with regular cycles, and non of the complications
o one of the side effects of injectable contraceptives Weight gain
o subdermal implants :
These are capsules placed the skin of a women arm that slowly release a progestin into the blood
stream.
o Vaginal rings?
1- Ring introduced by the end of cycle and left in the vagina for 21 days
2- It is slowly releasing hormone device
3- At first gestagens were used but now combined oestrogen and gestagens ring are available
4- Hormones are absorbed from the vaginal mucosa enter the circulation and act as OCP
o the female sterilization :
It is a permanent method for contraception. It entails tubal occlusion by cutting, clipping of both
fallopian tubes to prevent egg fertilization
o one of the complication of female sterilization: Pelvic congestion (post ligation syndrome)
o Options for emergency contraception
1. Morning after pills (EE+ Progesterone) 2 tablets /12hrs
2. IUD insertion
3. RU 486 MIFEPRISTONE (Antiprogesterone effect)
Emergency contraceptive pills
A. PROGESTINE- ONLY PILLS REGIMEN
First dose of 0.75 mg of levonorgestrel should be taken as soon as possible but within 72 hours
after unprotected intercourse. Repeat dose 12 hours after first dose
Pills containing 0.75 mg of levonorgestrel = 1 pill per dose pills containing 0.0375 mg of
levonorgestel = 20pills per dose pills containing 0.03 mg of levonorgestrel = 25 pills per dose
B. Combined oral contraceptive pills regimen
Each dose should contain at least 0.1 mg of ethinyl estradiol and 0.5 mg of levonorgestrel
which equals 4 tablets of the standard low dose COCs
First dose must be taken within 72 hours after unprotected intercourse. Repeat dose 12 hours
after first dose
- Low dose COCs= 4 pills per dose
- High dose COCs= 2 pills per dose
Side effects: nausea, vomiting , headaches, dizziness, fatigue, breast tenderness, irregular
bleeding and spotting

77
 GYNA REVISION NMT11

Diagnostic procedures +clinical aprroach to gyna

Exam questions

Indications of laproscopy in gyna (june 2005)
For mcqs
o therapeutic application of ultrasongraphy in gynagology
1- U/S guided follicular aspiration as a part of IVF programs
2- U/S guided aspiration of simple cysts
3- U/S guided drainage of ascites
o Advantage of operative laparoscopy
• Minimal hospital stay & early return to work
• Minimal patient discomfort
• Minimal patient adhesion & therefore minimal iatrogenic infertility
• Better cosmetic results
• Rare wound complications
• Allow proper inspection & excludes the need for what is called exploratory laparotomy.
o swellings of the broad ligament
1. Broad ligament cyst:
Sometimes it is large enough to be felt per abdomen. The cyst is of limited mobility & bimanually it
is lateral to the uterus, which is displaced to the opposite side.

2. Broad ligament heamatoma:

This may occur due to rapture of the tubal pregnancy in the broad ligament or due to rupture of
a varicose vein in the broad ligament or it may occur in cases of incomplete rupture of the uterus
where a cervical laceration on either side extends upwards to the part of the lower segment
between the two layers of the broad ligament. It may be also due to improper haemostasis after
abdominal operation on the pelvic organ especially operation done to remove a board ligament
cyst or tumor. There is a cystic swelling to one side of the uterus displacing it to the opposite
side, associated with the climical picture of the internal hemorrhage.
o Doppler ultrasound is a mode of ultra sound used to study blood flow in different blood
vessels.
o Laparoscopy is a procedure which allows direct inspection of the peritoneal cavity & pelvic
organs by introduction of an optic lens through the umbilicus after properly insufflating the
peritoneum with Co2 gas. The procedure also allows the performing of variable types of pelvic
surgery.
o The procedure of hysteroscopy entails the introduction of lens inside the uterine cavity
through the cervix after distending the uterine cavity with suitable medium (CO₂- saline- glycine
1.5%) to visualize the endometrial cavity & perform variable intrauterine operative procedures.

78